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 reviews 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 Association, 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 reprinted 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, biochemical structure and physiological effects-or on their social impact, 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 sociological 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 nowhere as evident as with regard to these four types of psychological

disturbance: (1) the narcissistic personality disorders, (2) the perversions, (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 comprehended 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 weakness in the core of his personality. He suffers from the consequences 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 delinquent 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 symbolically 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 selfconfident; 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 solutions which they provide are impermanent, that in essence they

cannot succeed. The praise which the narcissistically disturbed individual 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 system 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 childhood situation of the future addict. It is evidently of great importance in the present context to determine certain details concerning the behavior of the addict’s parents when he was a child. We

might ask, for example, whether they had been lenient or strict, or

whether their identities (e.g., as male and female; or, occupationally,

the mother as a housewife, the father as a truckdriver, etc.) were

hazy or well defined. Yet, having obtained the answer to these and

similar questions, we will look at the significance of the sociopsychological data concerning parental behavior with different

eyes when we examine them against the background of our knowledge concerning the factors that contribute to the child’s ability to

build up a strong and cohesive self and, in the obverse, concerning

the factors that stand in the way of this crucial developmental task.

Just as we know, from the point of view of the physiologist, that

a child needs to be given certain foods, that he needs to be proviii
PREFACE

tected against extreme temperatures, and that the atmosphere he

breathes has to contain sufficient oxygen, if his body is to become

strong and resilient, so do we also know, from the point of view of

the depth-psychologist, that he requires an empathic environmentspecifically, an environment that responds (a) to his need to have his

presence confirmed by the glow of parental pleasure and (b) to his

need to merge into the reassuring calmness of the powerful adultif he is to acquire a firm and resilient self. It is not enough to obtain answers to questions such as whether the mother’s attitude

toward toilet training is strict or lenient, for example, or whether

the father’s work-identity is clearly defined or not. The crucial

question concerns the adequacy or inadequacy of the parents as the

self-objects of the child, i.e., the adequacy or inadequacy of the

parents at a time when they are still performing for the child the

psychological functions of self-esteem regulation which the child

should later be able to perform on his own, the adequacy or inadequacy of the parents at a time in other words when the child still

experiences them predominantly as extensions of himself or experiences himself still predominantly as part of their strength. The

crucial question then is whether the parents are able to reflect with

approval at least some of the child’s proudly exhibited attributes

and functions, whether they are able to respond with genuine enjoyment to his budding skills, whether they are able to remain in

touch with him throughout his trials and errors. And, furthermore,

we must determine whether they are able to provide the child with

a reliable embodiment of calmness and strength into which he can

merge and with a focus for his need to find a target for his admiration. Or, stated in the obverse, it will be of crucial importance to

ascertain the fact that a child could find neither confirmation of

his own worthwhileness nor a target for a merger with the idealized

strength of the parent and that he, therefore, remained deprived of

the opportunity for the gradual transformation of these external

sources of narcissistic sustenance into endopsychic resources, i.e.,

specifically into sustaining self-esteem and into a sustaining relationship to internal ideals. Thus, in asking the crucial question concerning the factors in childhood which lead to the addiction-prone

personality, we will say that, in the last analysis, and within certain

limits, it is less important to determine what the parents do than

what they are.

Heinz Kohut, M.D.

Institute for Psychoanalysis

Chicago

ix

CONTENTS

Foreword - William Pollin ........................... v

Preface - Heinz Kohut .............................. vii

1

2

3

4

5

6

7

8

9

10

11

Introduction

Jack D. Blaine and Demetrios A. Julius. . . . . . . . . . . . 1

Psychodynamics of Drug Dependence: An Overview

Edward J. Khantzian and Catherine J. Treece . . . . . . . 11

Needed: A Theory (An Historical Perspective)

Herbert Wieder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Mr. Pecksniff’s Horse? (Psychodynamics in Compulsive

Drug Use)

Leon Wurmser ............................... 36

Substance Abuse: An Understanding From Psychoanalytic Developmental and Learning Perspectives

Stanley I. Greenspan. . . . . . . . . . . . . . . . . . . . . . . . . . 73

Self- and Object-Representation in Alcoholism and

Other Drug Dependence: Implications for Therapy

Henry Krystal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

The Ego, the Self, and Opiate Addiction: Theoretical

and Treatment Considerations

Edward J. Khantzian. . . . . . . . . . . . . . . . . . . . . . . . . . 101

Transference Phenomena in the Treatment of Addictive

Illness: Love and Hate in Methadone Maintenance

Virginia Davidson . . . . . . . . . . . . . . . . . . . . . . . . . . . .118

Implications of Psychodynamics for Therapy in Heroin

Use: A Borderline Case

Eugene H. Kaplan . . . . . . . . . . . . . . . . . . . . . . . . . . . .126

Ego Functions in Drug Users

William A. Frosch and Harvey Milkman . . . . . . . . . . . 142

Psychiatric Aspects of Opiate Dependence: Diagnostic

and Therapeutic Research Issues

George E. Woody . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

List of Contributors ................................. 185

List of Monographs. ................................. 186

xi

CHAPTER 1

Introduction

Jack D. Blame, M.D., and Demetrios A. Julius, M.D.

The Clinical-Behavioral Branch, Division of Research, NIDA, is

interested in developing a comprehensive and practical approach to

treatment of heroin-dependent people and drug abusers more

generally. This approach should be based on a theoretically sound

knowledge of the psychiatric status of the drug-dependent person

as well as the psychodynamics of drug abuse and psychological

dependence. The goal is to increase the quality of treatment and

likelihood of successful therapeutic outcome by focusing on the

individual’s intrapsychic dynamics and relevant external factors, in

order to select the most suitable treatment. Unfortunately, many

gaps still exist in our knowledge about use, abuse, and dependence

on opiates and other psychoactive drugs. One objective of this

monograph is to stimulate the development of new research directions and strategies for implementing innovative treatment which

take into consideration psychiatric evaluation and psychodynamic

understanding.

With this in mind, the first Technical Review of the Psychodynamics of Drug Dependence convened on April 2 and 3, 1976, in

Washington, D.C. Participants presented papers from which the substance of this monograph is primarily derived. To exploit the theoretical groundwork laid at this meeting, the technical review group

recommended an ongoing series of small working groups, each of

which would focus on a specific issue. Consequently, a second

review group convened on March 17 and 18, 1977, to focus specifically on diagnostic and therapeutic research issues. The second

group included some noted theoreticians and researchers in areas

related to drug dependence, among them Harriet Barr, Otto Kernberg, Gerald Klerman, George Woody, Charles O’Brien, Catherine

Treece and Henry Rosett, in addition to members of the first group

1
2 PSYCHODYNAMICS OF DRUG DEPENDENCE

who continue active research in the area. We wish to thank all of

these researchers and clinicians for the high caliber of interest and

effort they have contributed.

The overview presented in chapter 2 was written before the

second conference took place and therefore does not refer to it. We

are, however, gratified to be able to include Dr. Woody’s report as

the final chapter of this monograph.

BACKGROUND

Before the early 1970’s, an effort was made with each patient in

drug abuse treatment to achieve an understanding of the specific

personality structure and the psychodynamic factors contributing

to the patient’s drug dependence. This understanding formed the

basis for therapeutic goals and course. Drug abuse treatment has

historically utilized therapeutic communities, residential centers,

outpatient drug-free treatment clinics, and detoxification clinics.

These treatment modalities have used group therapy, psychopharmacological agents, individual counseling, family therapy

and/or a therapeutic milieu as primary behavioral change-producing

techniques.

The failure of heroin withdrawal alone as a treatment with the

goal of long-term continued abstinence has been voluminously

documented. At best, medically controlled detoxification had only

immediate and temporary value as a first step in a comprehensive

rehabilitation program. Medically regulated detoxification reduced

human suffering and freed individuals from their physical dependence on heroin, which permitted a shift in attention to other more

constructive pursuits. However, even long periods of confinement

in a hospital, prison, or residential facility with traditional psychotherapeutic intervention have not significantly altered the subsequent relapse to heroin for the vast majority of addicts.

The advent of the methadone maintenance treatment modality

and its large-scale application in the late sixties and early seventies

in response to an epidemic increase in heroin addiction made

dramatic alterations in the philosophy, process, and economics of

heroin treatment. Methadone has proved to be an extremely effective pharmacologic agent. The drug is capable, when prescribed and

taken properly, of providing symptomatic relief of the most apparent symptoms of heroin dependence: abstinence symptoms, craving,

and blockade of euphoria resulting from opiate injection.

This medication can remove the need for using illicit heroin and

potentially allows the individual to alter his deviant lifestyle. How-
BLAINE AND JULIUS: INTRODUCTION 3

ever, methadone alone does not alter the underlying psychopathology manifested in compulsive drug abuse and dependence or the

unbearable feelings or fears that may trigger the compulsion.

Methadone maintenance is in many ways analogous to the use of

phenothiazines in the treatment of schizophrenia. The phenothiazines have dramatic effect on the psychotic manifestations of

decompensated schizophrenics, facilitating long-term psychotherapy

and rehabilitation, which are important treatment components.

The availability of an effective symptomatic treatment modality,

coupled with rapid expansion of the heroin-dependent population,

produced an increased demand for treatment. As a result, treatment

resources did not keep pace with the increased demand for treatment, producing waiting lists, expanded patient case loads, utilization of paraprofessional counselors, and an emphasis on costeffective treatment. All these factors contributed to a shift in treatment emphasis from intrapsychic factors to external social and

economic aspects of the client’s life. Goals of treatment also concomitantly shifted from basic personality growth and comprehensive personal rehabilitation to social rehabilitation or merely changing social behaviors. Evaluation of outcome focused on lifestyle

(e.g., use of illicit drugs and alcohol abuse, illegal activity, general

health, arrests) and social productivity (e.g., employment, educational achievements, marital stability).

Despite the substantiated positive effect methadone maintenance

has had for many thousands of heroin-dependent individuals on

social rehabilitation, the ability to become and remain drug free

after treatment has again become a criterion of success for many of

those who articulate drug policy. However, relatively little effort

has been made to understand or treat the psychopathology which

contributes to the individual’s psychological dependence on heroin

and prevents meeting that criterion.

Recently, there has been renewed interest in developing a deeper

comprehension of the psychodynamics of drug dependence in the

light of recent advances in psychoanalytic ego theory. Much of this

interest has been generated by accounts of the thoughtful and provocative clinical work of the psychoanalytic clinicians represented

in this monograph working with drug-abusing populations. These

clinicians have proposed major theoretical advances toward achieving an understanding of drug abuse and psychological dependence.

Many have extended this theoretical framework to propose implications for psychotherapy and treatment of drug abuse and especially psychological drug dependence. These contributions, as well

as those of others represented in the bibliography, are discussed in

the following paper by Khantzian and Treece.
4 PSYCHODYNAMICS OF DRUG DEPENDENCE

DIAGNOSIS

A central issue in evaluating different treatment methods for

drug abuse has been increasing dissatisfaction with the uncritical

acceptance of “drug abuse” as a diagnostically homogeneous term.

Both the clinical and research literature look generically at the

effects of treatment on drug abusers, and only rarely has a clinician

or scientist attempted to develop a treatment directed at a more

specific diagnostic entity.

Reemphasis on psychiatric diagnosis implicitly reflects a conviction that “drug abuse” is not a genuine diagnostic entity. Rather, it

is an attempt to categorize people in terms of an overt behavior

which may express several genuine diagnostic entities and which

may at times probably exist in the absence of psychopathology.

Yet it is difficult to see how treatment can be efficacious, especially

for long-term, rehabilitative goals, so long as we continue to treat

individuals having different psychopathologies with a hodge-podge

of treatments specific to none of them.

Some may question whether the specialty of psychiatry currently

possesses the technology for specific psychiatric diagnosis. It is true

that diagnostic classification in psychiatry is in the process of

development and refinement in an attempt to integrate new information and perspectives generated by different schools of theoretical orientation, e.g., psychoanalytic ego psychology and biological

psychiatry.

The 1968 edition of Diagnostic and Statistical Manual of Mental

Disorders (DSM-II) prepared by the American Psychiatric Association represents an attempt to achieve this goal. The APA is currently developing a DSM-III to reflect changes in the field. Concurrently, each of the different schools of thought in psychiatry is

clarifying the field from its own unique perspective. As a result, the

scientific literature and popular press abound with a variety of diagnostic nomenclatures for psychiatric patients in general and drug

users and abusers in particular. However, this dynamic state of the

art and science of psychiatry should not be viewed as a limiting

factor. In fact, psychiatry has been undergoing change since its

inception. Generally, this process has resulted in advancement for

psychiatry as a medical specialty and better treatment for patients

having psychiatric illnesses. Thus, focusing the attention of psychiatric diagnosticians and innovative clinicians on the often-overlooked population of drug abusers has potential benefit for psychiatry as well as afflicted individuals.

DSM-II includes the category “drug dependence” (304) “. . . for

patients who are addicted to or dependent on drugs other than
BLAINE AND JULIUS: INTRODUCTION 5

alcohol, tobacco, and ordinary caffeine-containing beverages, and

unindicated or inappropriately taken prescribed drugs. The diagnosis requires evidence of habitual use or a clear sense of need for

the drug. The diagnosis may stand alone or be coupled with any

other diagnosis” (DSM-II, 1968, p. 45).

Indeed, the psychiatric diagnoses of “sociopathic personality

disorder” and “psychopathic personality disorder” have been used

by some writers in this field in the past, supposedly to clarify what

and who a “drug abuser” is. However, this type of diagnostic effort

has merely led to the widespread feeling that these diagnostic labels

are no more clarifying than the descriptive label “drug abuser”

itself. In fact, these diagnostic categories have now disappeared

from the official American Psychiatric Association’s Diagnostic and

Statistical Manual of Mental Disorders (DSM-II), and have been replaced by the term “antisocial personality” (301.7). The official

definition reads, in part, “This term is reserved for individuals who

are basically unsocialized and whose behavior pattern brings them

repeatedly into conflict with society. They are incapable of significant loyalty to individuals, groups, or social values. They are grossly

selfish, callous, irresponsible, impulsive, and unable to feel guilt or

to learn from experience and punishment . . .” (DSM-II, 1968,

p. 43). Although this may characterize some drug-dependent individuals, it does not characterize the vast majority. The language of

this diagnostic category implies, in effect, that such people are unfit

to interrelate with “normal” people and should be seen as a deviant

subgroup for whom there is probably little help possible.

Applying this type of diagnosis to the drug-dependent’ person is

of little practical value. What is necessary for practical treatment is

either to identify other major, treatable components of these individuals’ psychic constellation or to more explicitly and completely

diagnose (Gr., dia - through, between; gignoskein - to know) what

we now call antisocial personality and other applicable subdiagnoses. With regard to the first necessity, researchers have, for example, begun to demonstrate the existence of a subgroup of dependent individuals who can be diagnosed as depressed.

In an unpublished report, Senay (1975) has demonstrated the

existence of significant depressive symptomatology in a group of

opiate users in Chicago. Weissman, et al. (1976) have also demonstrated the same result. Using standard rating scales of depression,

they have shown that a substantial minority of methadone-maintained patients are, in fact, clinically depressed. The implications of

such results, of course, lead to a refinement of treatment plans for

such patients. In this regard, the double-blind placebo-controlled

pilot study of Woody, O’Brien, and Rickels (1975) has shown a
6 PSYCHODYNAMICS OF DRUG DEPENDENCE

significant improvement of methadone maintenance patients who

received the antidepressant agent, doxepin, over those who received

the placebo. However, this was only a preliminary study, and longer

term studies utilizing similar designs are now underway to validate

these results. When these studies are completed, they may shed light

on which type of treatment is most effective for this subgroup of

drug-dependent individuals.

From this exemplary exploration of a new diagnostic area we see

that there is indeed diagnostic thinking already available to identify

one subgroup of drug users. This thinking also has direct implications for treatment of these individuals. Diagnoses within the

general category of “depression” are also continually being refined.

Psychopharmacologists have identified syndromes of retarded depressions, agitated depressions, hostile depressions, reactive depressions, and endogenous depressions. What is of value in this subclassification is that each of these subgroups seems to do better within

certain specific treatment regimens. For example, Gershon, Hekimian, and Floyd (1967)’ have shown, in a placebo-controlled study,

that 70 to 80 percent of patients with retarded depressions do best

with the tricyclic antidepressants. Hollister and Overall (1965) have

also lent supporting evidence for this treatment, in that they found

this group of depressions to respond best to imipramine (a tricyclic

antidepressant), while thioridazine (a phenothiazine) was of little

value. However, in hostile depressions, the same study found

thioridazine and imipramine to be equally effective. And in the

reactive depressions, if the patient is receptive to verbal therapy,

psychoanalytically oriented psychotherapy produces equally effective, if not superior, results to chemotherapy. Other schools of

theoretical orientation may view depression differently, resulting

in other diagnostic terminology, e.g., primary and secondary affective disorder or manic-depressive disease. Nevertheless, the foregoing and other studies have shown how more specific differential

diagnoses can improve treatment regimens with correspondingly

enhanced chances for successful outcomes.

Returning to the more difficult classification of character or

personality disorder such as sociopathic, psychopathic, antisocial,

narcissistic, and borderline personality disorders, how can we proceed in the same fashion as we have shown is possible in the classification of depression? Part of the answer may lie within recent

advances in psychoanalytic thinking. The work of Greenacre,

Kohut, and Kernberg has deepened and expanded the understanding of character pathology in general, and the so-called borderline

and narcissistic personality disorders in particular. This pioneering

work, drawing on solid observational and treatment interaction
BLAINE AND JULIUS: INTRODUCTION 7

data, is evolving a complex and sophisticated theoretical base upon

which can be built further concrete understanding of an enigmatic

region of personality pathology. There is, however, a need to distill

and condense much of this thinking down to identifiable subgroups,

which then would have specific implications for specific treatment

regimens. In applying these new theoretical insights to the diagnostic problem of “drug abusers,” as well as developing new theoretical

avenues of their own, researchers such as Khantzian, Wurmser,

Krystal, Frosch, Wieder, and Kaplan have all begun the work of distillation of the theoretical work already accomplished. Their work

is now leading to more practical, specific, and operational formulations of diagnosis and consequent treatment planning of drugdependent individuals.

The process of arriving at operational diagnostic subcategories,

therefore, moves from the more generic to descriptive categories

sufficiently refined to indicate actual treatment. Diagnostically, we

proceed from general descriptive terms such as “drug abuser” to

more refined descriptors that indicate demographic variables. These

include race, socioeconomic status, criminality, exposure to drugs,

ethnic background and social environment, among others. These

factors aid in understanding drug-dependent individuals, but do not

in themselves dictate a complete treatment regimen. Further refinement leads to more specific diagnostic categories such as those

found in the APA’s DSM-II. These diagnoses include subgroups

such as depressive neurosis, psychotic depression reaction, manicdepressive illness, or those with descriptive personality disorders.

Categorization can stop at this point or proceed to further refinement, as we have seen in the subgroupings of depression. We advocate further refinement of the psychiatric diagnoses of the DSM-II.

This refinement may be especially critical within the category of

the antisocial, borderline personality. Within this subgroup we can

begin to look at measures of such personality components as reality

testing, structure of defense mechanisms, intactness of ego and

super-ego functions, degree of grandiosity, identity diffusion,

quality of object relations, and control of affects.

Can we, in fact, begin to define subgroups of individuals on the

continuum of character pathology predominantly characterized by

defects in one or more of these personality categories? To do so

could have significant implications for differentiating treatment

approaches. This process of refinement and exploration into undefined areas of personality diagnosis is undertaken by the contributors to this monograph.
8 PSYCHODYNAMICS OF DRUG DEPENDENCE

TREATMENT

Improved psychiatric diagnosis in the field of drug abuse has at

least four implications for treatment. The first and most immediately apparent is that patients could, when indicated, receive individual psychotherapy, group therapy, family therapy, or psychopharmacologic agents directed at their psychopathology, such as

those already indicated for treatment of depression. This would

occur in addition to opiate maintenance therapy, vocational training, and the like, directed at their chronic behavior disorder and

social circumstances.

Evolving sophistication in diagnosis of drug-abusing individuals

will have implications for those who are evaluating and treating

these people. These developments will increase the demand on

therapists to be more interested in, to show greater understanding

of, and to have deeper empathy for the people they are helping.

Specificity in diagnosis will also mean specificity in treatment.

This should then lead to clinic treatment centers where multimodality. approaches allow a wide range of treatment regimens

for a wide range of subgroups of “drug abusers.”

Currently, in many treatment programs the major responsibility

for the assessment of psychological needs and provision of psychological treatment is given to paraprofessionals who are not trained

in psychiatric diagnosis and treatment. Unfortunately, these wellintentioned counselors are not able to make use of the potentially

valuable information available to them in planning and providing

treatment services. Thus, the increased participation of psychiatrists

in treatment clinics may provide training opportunities and supervision for paraprofessionals.

A more subtle implication would be the impact on the clinic as a

treatment milieu. Currently, methadone clinics, for example, are

generally structured according to the personal whim of their director or dominant staff members. They can be confronting or lax, can

be structured or allow patients great latitude, can be only dispensaries or very active in their patients’ lives. These different clinical

structures have radically different implications for different personality types and for different psychopathologies. The way a clinic

interacts with a patient can mean the difference between success

or failure in initiating and keeping the patient in treatment. Similarly, the way a clinic is structured is important for the success it

will have with different types of psychopathology. For example,

with the borderline personality, the need to provide sufficient external structure is felt to be a precondition for treatment. The role

and effect of methadone, residential communities, behavioral
BLAINE AND JULIUS: INTRODUCTION 9

therapy, or clinic regulations in providing this need are yet to be

determined. Hence, diagnosis is a necessary condition for providing

a clinic milieu that will enhance treatment.

Finally, increasing our awareness of the types of psychopathology found in the drug abuse population will also increase our

awareness of the psychotropic effects of drugs of abuse. Forexample, it is possible that heroin may have a beneficial effect on some

individuals and may even constitute a form of self-medication. But

our current lack of diagnostic specificity hinders understanding the

function of abuse drugs in the psychopathology of our patients. It

also hinders the exploration of when and how to replace abused

drugs in those patients for whom the drug may serve a useful

function.

CONCLUSION

Our awareness of the importance of diagnosis in drug abuse is

only now emerging. Some of the relevant research questions raised

are: Are there sufficient theoretical positions currently available to

generate testable hypotheses for diagnosis and treatment? Is there a

need to develop a more cohesive theory of the psychopathology

and psychodynamics of compulsive abuse and psychological dependence? Do the manifested symptoms of compulsive abuse and

psychological dependence (for example, narcotic hunger or craving,

abstinence, euphoria) reflect structural defects of symbolic defense

mechanisms? Is there benefit to be gained from availability of comprehensive psychotherapies in treatment programs? Can more

effective treatment approaches be devised utilizing current knowledge? What are the implications for maintenance drug therapy or

use of other psychopharmacologic agents? What are the implications for length and course of treatment? Would continued treatment of the patient after the symptom of drug dependence disappeared be beneficial, as in other chronic relapsing disorders with

cycles of remission and exacerbation? What operational formulations can be developed for clinical testing?

There are also questions that relate to the psychopharmacology

of opiates and other abused drugs: Are there specific psychotropic

effects of opiates which are psychotherapeutic for the individual

user? Do these effects differ for users with varying types and degress of psychopathology? What is the nature of these actions? Do

they help bolster underdeveloped defense mechanisms necessary to

master tensions and anxieties of daily life problems or intrapsychic

conflicts?
1 0 PSYCHODYNAMICS OF DRUG DEPENDENCE

The focus of this monograph on the illicit abused drugs, the opiates in particular, represents only a small proportion of abuse substances and habitual behaviors leading to a variety of difficulties for

man. However, the abuse of illicit drugs may be viewed as the most

deviant habitual behavior on a continuum which includes excessive

use of alcohol, tobacco, and food. Perhaps a more complete understanding of the more deviant behavior will shed light on the more

common but frequently self-destructive behaviors.

The Division of Research, NIDA, hopes to stimulate definitive

research in these areas. By encouraging well-conceptualized, welldesigned research protocols, which are also placebo-controlled and

double-blinded when necessary, we hope to provide convincing

answers to these complex questions for researchers and therapists

alike.

The papers presented in this monograph are an initial effort

addressed to some of these questions by a group of psychiatrists,

most of whom have had considerable experience with patients who

are drug abusers and consequently have developed some feeling for

the complexity of these questions. The papers range from the

theoretical to the clinical and from broad-scope issues to quite

precise, limited studies. Collectively, they give a flavor of the current state of the art.

REFERENCES

Diagnostic and Statistical Manual of Mental Disorders (DSM-II). Washington,

D.C. : American Psychiatric Association, 1968, p. 43.

Gershon, S., Hekimian, L.J., and Floyd, A. Pre-clinical-clinical correlation of

antidepressant activity: Controlled study of gamfexine and imipramine,

Curr Ther Res, 9:349-354, 1967.

Hollister, L.E., and Overall, J.E. Reflections on the specificity of action of antidepressants. Psychosomatics, 6:361-365, 1965.

Overall, J.E., Hollister, L.E., Meyer, F., Kimbell, I., and Shelton, J. Imipramine

and thioridazine in depressed and schizophrenic patients. Are these specific antidepressant drugs? JAMA, 189:605-608, 1964.

Senay, E. Depression in Drug Abusers. Chicago, University of Chicago, 1975

(unpublished report).

Weissman, M., Slobetz, F., Prusoff, B., Mezritz, M., and Howard, P. Clinical

depression among narcotic addicts maintained on methadone in the community, Am J Psychiatry, 133(12):1434-1438, December 1976.

Woody, G., O’Brien, C., and Rickels, K. Depression and anxiety in heroin

addicts: A placebo-controlled study of doxepin in combination with

methadone, Am J Psychiatry, 132(4):447-450, April 1975.
CHAPTER 2

Psychodynamics of Drug

Dependence: An Overview

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

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, ClinicalBehavioral 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 con11
1 2 PSYCHODYNAMICS OF DRUG DEPENDENCE

tributors 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
KHANTZIAN AND TREECE: AN OVERVIEW 1 3

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.
1 4 PSYCHODYNAMICS OF DRUG DEPENDENCE

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.
KHANTZIAN AND TREECE: AN OVERVIEW 1 5

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 auton-
1 6 PSYCHODYNAMICS OF DRUG DEPENDENCE

omy 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.

SUMMARY AND OVERVIEW OF THE MONOGRAPH

Dr. Wieder’s paper begins the series of papers in this monograph

with a proposal that we proceed from an historical perspective. He

takes us back to an early period at Lexington where Federal efforts

were first made to unravel the enigma of addiction and drug dependence through collaborative efforts of behavioral and biological

scientists and psychiatrists. He recounts his experience as a member

of these pioneering researchers, noting their difficulties even then in

unifying a body of knowledge generated by researchers and clinicians who had yet to agree upon basic definitions of the phenomenon, the nature of the problem, or the constructs to be used in their

study. Dr. Wieder reminds us of the interdependency of theory and

data in scientific investigation, and challenges the technical review

group to learn from what has gone before them. Before generating

yet more voluminous data, he pleads for systematic evaluation of

what has already been studied and learned. Wieder observes that despite the accumulation of massive, valuable data at Lexington, they

were unable to develop a valid psychological definition or theory of

addiction because of a restrictive medical model that was prevalent.

Psychoanalysis was similarly unequal to the challenge as a result of

its own definitional problems, wherein addiction was too narrowly

defined as “an impulse problem” and therefore not within the

domain of psychoanalysis. Because of exclusion of addicts from

treatment based on inadequacies of earlier theory, plus the low

socioeconomic background of most opiate addicts, few such patients were seen by analysts. Based on these trends, Wieder laments

that the Lexington experience suffered from an absence of analysts,

and that when analysts attempted to formulate an understanding of
KHANTZIAN AND TREECE: AN OVERVIEW 1 7

addiction, their formulation suffered because of an absence of

comprehensive, objective clinical data. Wieder believes that Rado

made a good beginning and that his insight, “not the toxic agent,

but the impulse to use it,” could have been an important cornerstone for a psychoanalytic theory of addiction. Wieder is skeptical

that the application of any particular formulation by itself will

greatly improve our treatment capabilities; however, he is firm in

his conviction that psychoanalysis represents the most meaningful

method of understanding human behavior and development, and

applied to addiction, will make its greatest contributions in the

areas of formulating and understanding the problem and in theory

development.

The next four papers plunge directly into the rich complexity of

psychoanalytic formulation. These papers exemplify the fact that

psychoanalysis is not one theory, but many part theories, each

addressing a different metapsychological level or a different explanatory perspective. This will be demanding reading for non-psychoanalytic readers, but well worth their while. As Dr. Wieder notes in

closing, reminding us of the mandate of our work and the promise

that it brings to this diverse field, psychoanalytic theory is the

“most comprehensive view of human behavior” currently available.

Dr. Wurmser begins by reminding us of the importance of appreciating the severe psychopathology in compulsive drug users. He

cautions the reader against the impulse to seek simple or expedient

solutions to an immensely complex problem. In elaborating and expanding upon his own earlier observations (1974), Dr. Wurmser

challenges us greatly to apply already complex concepts of narcissism, affect defense, compulsivity, splitting, psychological boundaries, and externalization to the analysis and understanding of the

etiology of compulsive drug use. However, in pursuing the challenge

and complexity of Wurmser’s thinking, new and enriching vistas of

understanding as well as valuable hints as to where we should be

looking further are opened up for us. His meticulously developed

model for what he considers the direct and specific psychological

antecedents of compulsive drug use is an object lesson in the rewards of patience and perseverance in the face of such complexity.

In this paper the knowledgeable clinician will find many occasions

to nod his or her head in recognition as Dr. Wurmser unravels the

threads of behavior and motivation, and puts them into a model

which manages to allow for specific application within the framework of highly abstract concepts. And by reconsidering compulsive drug use in the light of more recent conceptual developments in

psychoanalytic theory, Dr. Wurmser enriches and contemporizes

both the drug field and the theories themselves.
1 8 PSYCHODYNAMICS OF DRUG DEPENDENCE

Dr. Greenspan in his paper focuses primarily on the developmental and adaptational perspective within a psychoanalytic model

of learning. He summarizes the major developmental challenges of

early life, starting with the earliest phases of achieving homeostasis

and need satisfying attachment, through subsequent phases of separation, individuation and capacity for mental representation (as

developed by Mahler and Piaget). He stresses how optimal nurturante and encouragement from the environment (as primarily represented by the mother) fosters adequate mastery of these phases by

the infant, and leads to the development of stable ego structures

and capacities to manage drives and object relations. To the extent

that the individual is overly deprived or indulged in his/her development, varying degrees of ego impairment occur and drugs then

come to substitute and compensate for the developmental defects

and impairments. Greenspan specifically delineates how the lack of

integrated ego structures and differentiated drive organization in

certain individuals leave them particularly susceptible to environmental reinforcers and influences. In the case of addicts, drugs as

well as many other environmental influences become powerful

determinants of behavior in the absence of adequate ego structures

and drive organization. Notwithstanding a difference in terminology, this formulation is consistent with and bears important resemblance to Krystal’s notions of developmental impairments in the

stimulus barrier and the failure in differentiation of affects. It also

parallels Wurmser’s thinking, wherein he emphasizes the addict’s

need to externalize and to act in the absence of adequate ego

defenses.

In the next paper, Krystal clarifies the defensive function of the

“splitting” mechanism in drug-dependent individuals, and traces the

enormous problems that addicts have with ambivalence, particularly

aggression. He discusses the nature of childhood trauma which can

lead to undifferentiated or regressed affects and poor affect tolerance. Such trauma, in later life, may result in a massive “walling

off” of self- and object-representations and an inability to provide

comforting and self-care maternal modes for the self, or to tolerate

aggression toward significant objects. Krystal cogently describes the

viscissitudes of these trends in the transference when long-term

psychotherapy is undertaken with such patients. The work of

therapy centers on helping the individual to overcome the fear of

closeness with the therapist (i.e., vis-a-vis rekindled childhood longings and fears of aggressive impulses), learning to grieve effectively,

owning up to one’s destructive feelings, and finally, overcoming the

barriers that prevent effective comforting and care of oneself.

Krystal suggests that success in this process invalidates the need for
KHANTZIAN AND TREECE: AN OVERVIEW 1 9

the placebo and pharmacologic action of the drug to effect access

to these parts and functions of the self.

Dr. Khantzian’s paper serves to provide some perspective on what

has gone before, by reviewing and pulling together the major

themes embodied in the foregoing papers and in other recent literature. He then explores aspects of ego function related to drive defense and “self-care.” He proposes a gap and/or impairment in the

ego function of self-care. He relates this to failures in internalization

of vital functions which have left the individual vulnerable to a

whole range of hazardous behavior and involvement, but in particular, to addiction. He then goes on to review how certain narcissistic

processes and resultant defenses are related to unique characteristics

and traits of addicts that impair such individuals in obtaining satisfaction in their involvement with people, work and play.

The next three papers offer a sampling of clinical case material

and research which follows from the preceding formulations.

Dr. Davidson’s paper brings a psychoanalytic understanding to an

evaluation of methadone maintenance clinics as a treatment modality. She has provided valuable flesh and substance to our often

made generalizations about addicts’ prominent reactions of splitting,

projection, impaired reality sense, other primitive defenses and narcissistic rage. She accomplishes this through her compelling observations and descriptions of the very frequent and troublesome

transference distortions that occur between patients and staff in

methadone clinics. Her clarification that the often observed extreme, intense and labile outbursts by patients in methadone clinics

have irrational and overdetermined origins in the patient’s past (and

are not simply a function of clinic setting or social background), is

a helpful reminder to the most seasoned staff member, and may

also act as a helpful guide to the novice staff worker in a methadone

clinic. Her paper should be required reading for all staff and administrators working in a methadone clinic.

Kaplan presents an in-depth case report about a heroin addict

and her family. The detailed clinical description of this woman

highlights some of the severe narcissistic disturbances and pathological regression and fixation present in so many addicts. The pathological disturbances of the parents are also well spelled out and

give us clear understanding of this patient’s developmental failures

and troubled identification with her parents. In the absence of

mature defenses and an enabling ego (ideal), such patients have few

choices but to adopt regressive oral satisfactions.

Finally, Frosch and Milkman in their paper discuss their research

findings which appear to support the observations of Wieder and

Kaplan, Khantzian and others, that selection of specific “drug of
2 0 PSYCHODYNAMICS OF DRUG DEPENDENCE

choice” is determined by particular ego vulnerabilities, dispositions

and drive strengths: The drugs are used by such individuals syntonically to either augment or bolster certain modes and styles of

adaptation, or to compensate for certain ego deficiencies. Frosch

and Milkman’s findings and their conclusions further lead them to

concur with Wieder and Kaplan that the drugs are used to induce

ego states reminiscent of a similar state in earlier developmental

phases (along lines proposed by Mahler). Whereas the heroin addict

uses opiates to achieve a “narcissistic blissful” state of union dating

back to a very early phase of development, the amphetamine user

takes advantage of the stimulating action of the drug to bolster a

grandiose sense of omnipotence through movement and activity

akin to the “practicing period” at a slightly later period of development (around one and one-half years old).

DISCUSSION

In the following collection of papers the reader will be rewarded

by the richness of insight which a psychodynamic understanding

can bring to bear on the drug-problems field. He/she will no doubt

also encounter some of the difficulties inherent in an approach

which attempts to do justice to human complexity and individuality. As a beginning, one need only note the plethora of terminologies and definitions to conclude, as Dr. Wieder points out in the

opening paper, that there is an urgent need to integrate and clarify

our definitions and knowledge to date before attempting to open

further vistas. Greenspan’s paper, for instance, addresses the generic

construct of “substance abuse,” while Khantzian and Davidson are

writing specifically about heroin addicts; Krystal refers to “other

drug-dependencies” but appears to center his observations around

the problems of alcoholism. This difference in focus leads to the

apparently contradictory emphasis on the adaptive advantage of

long-acting drugs by Wurmser and Khantzian on the one hand, and

of short-acting drugs by Krystal and Raskin on the other. Wieder

specifically redefines drug addiction around a concept of compulsiveness in distinction to the traditional criterion of physical dependence; yet Frosch and Milkman in their experimental work

based on theoretical conceptualizations similar to Wieder’s, define

drug dependency operationally in terms of specific amount and frequency of drug use.

1As indicated in chapter 1, this paper was written before the second meeting

which is reported by Woody in chapter 11.
KHANTZIAN AND TREECE: AN OVERVIEW 2 1

Admittedly, some of these difficulties are only semantic, and

other apparent differences stem from preferences in focus. But a

close look suggests some basic areas which require fuller consideration before a unitary conceptualization of the problems and issues

can be derived. Diagnostic considerations constitute a case in point.

Both Wieder and Kaplan consider drug use as symptomatic but not

pathognomic, thus underscoring observed diagnostic heterogeneity

of drug-using patients, even within a specific type such as narcotic

addicts. Wurmser, on the other hand, finds it more useful to consider the varieties of pathological drug use from the base of a common constellation of personality features. Nevertheless, with both

formulations, the “drug of choice” phenomenon emerges as a reference point for systematizing observations, and thus provides a common meeting ground. Greenspan’s proposition that the specific level

of developmental impairment has predictive value in relation to the

malignancy of the drug taking, and thus to prognosis, provides

another organizing dimension.

The relationship of the drug to the psychopathology of drug

users is another aspect of the diagnostic puzzle. Khantzian suggests

that drug use and dependency tend to mask the nature of the

underlying psychopathology, and that diagnostic assessment must

be deferred until drug-taking behavior is under control. Wurmser,

on the other hand, tends to view drug use as “coextensive” with the

pathology, and as such, part and parcel of the dynamic and structural vicissitudes which constitute the specific nature of compulsive

drug use. Frosch and Milkman touch on what seems implied by the

foregoing, which is the very difficult problem of distinguishing the

effects of drug use from its causes. Their study provides a graphic

illustration of the sensitive interactions of drug and ego functions

by demonstrating statistically significant changes in ratings on a

wide range of intrapsychic functions following doses of drugs which

are minuscule by street standards. In different terms, Greenspan

makes a similar point in his discussion of the interactive aspects of

drug effect and ego organizations.

If the authors have technical differences of formulation or definition, there is nonetheless a welcome unanimity and explicitness in

their recommendations for treatment. The shared mandate of all

the participants in the technical review and in this monograph is,

above all, to provide input which will be applicable toward a

remedy for what everyone agrees is a painful and costly human

problem. In their statement of the problem, the authors’ collective

dictum is straightforward: That social and other factors notwithstanding, compulsive drug use and addiction in our society are indi-
2 2 PSYCHODYNAMICS OF DRUG DEPENDENCE

cative of psychological disturbance, which in the majority of

instances, is profound.

Several of the authors comment on public reluctance to accept

this position. Davidson notes that the wish to locate the cure for

addictive illness outside the patient’s psyche (e.g., with drug therapies alone, or via legal sanctions) indicates the same proclivity

which in the patient we identify as denial. Wurmser widens the

horizon of social commentary in drawing attention to all forms of

externalization, including but not limited to drug use, as the defense of our times. “In a sense,” Wurmser writes, “the addict-like

the paranoid-has been most successful in making the world serve

his inner defense . . . in forcing his surroundings near and far to play

their roles in what is originally an internal conflict.”

Each of the authors has courageously addressed the problem of

what constitutes realizable and adequate treatment. There appears

to be a consensus in this monograph that psychoanalytic insights

rigorously applied to the problems of addiction can make a major

contribution to the treatment of individuals in trouble with drugs.

The specific elaborations on treatment issues can be summarized in

terms of four constituents: these include, 1) multiple modality

approaches to do justice to the complexity and multiplicity of

determinants in pathological drug use; 2) a bi-phasic therapeutic

strategy consisting first of interim measures for keeping patients

available and intact until the second phase of longer range work in

psychotherapy can be firmly established; 3) the use of treatment

personnel who are fully trained and who hold the particular qualities needed for this kind of work; and 4) specificity of diagnosis

and treatment planning.

On hindsight, this prescription may seem self-evident. Yet,

although many current treatment options offer one or more of

these constituents, rarely do they combine all of them.

The call for multiple approaches in treatment heralds a refreshing

eclecticism which need not undermine the integrity of a unitary

theoretical framework. For example, Wurmser suggests utilizing

combinations of individual, group, and family therapy, together

with supportive medication, hospitalization, and vocational and

other forms of social counseling. Kaplan’s detailed case presentation

provides an illustration of the flexible use of a wide variety of resources brought to bear on a whole family. Krystal offers an example of the successful use of a team approach in the treatment of

alcoholics, particularly in the interest of utilizing therapeutically

the otherwise destructive transference splitting which occurs so

often with clinic or institutional patients.
KHANTZIAN AND TREECE: AN OVERVIEW 2 3

The second constituent of treatment, which overlaps the first,

counsels the need for, as Khantzian puts it, “initial treatment interventions to provide the structure and time that make the understanding and management of the addict’s problems possible.” Such

interventions serve to take into account the issue stressed repeatedly

in these papers, namely, the inadequacy of internal psychological

structures in so many pathological drug users. Such interventions

may include any or all of the multiple approaches considered above,

and Greenspan adds an additional dimension, in focusing consideration on why such individuals are particularly vulnerable to external

environmental influences.

The second phase of the bi-phasic approach is, of course, the

crux of the treatment, namely, long-term psychotherapy. The

necessity to think in terms of lengthy treatment, including the dependable availability of the primary therapist, is particularly well

elaborated by Krystal as he details the specific unfolding of issues

in the treatment process. He reminds us of the often misunderstood

fact that as old defenses are given up, the patient appears to himself

and to the world to be “worse” as he begins to experience his own

feelings and impulses which were heretofore undefined, externalized, or otherwise thwarted. And it is particularly for this reason

that at this point “dependence upon the therapist is extreme, and

no substitutes are acceptable.”

Thus the third constituent emerges as the elaboration of those

processes which must occur in psychotherapy proper, and in that

context also, the qualities the therapist must bring to the task.

Khantzian discusses the delicate balances that the effective therapist must maintain in his work with such patients. There must be

confrontation, but it must be done with consistent and empathic

respect for the tenuousness of those mechanisms of defense by

which self-esteem is maintained, however troublesome or offensive

they may appear to the casual observer. Similarly, the therapist

must tread the fine line between closeness and distance as problems

with primary relationships emerge into the therapeutic relationship.

Khantzian’s formulation regarding drugs as substituting for defective and absent defenses, and safeguarding against overwhelming

and disorganizing affect, lead logically to advocating the use of psychotropic agents as part of the therapy while issues of extremes of

self-indulgence and self-denial are negotiated. Kaplan, Krystal and

Wurmser all cover similar territory. The modifications of a strictly

transference-oriented approach are stressed with the requirement

that the therapist play a real role in the patient’s life, including limit

setting, but again, they caution against the naive application of

other extremes. Thus, Wurmser, too, stresses balances, between
2 4 PSYCHODYNAMICS OF DRUG DEPENDENCE

nurturing and engulfment, between active and intrusive intervention, and between emotional distance and availability. Davidson’s

contributions are particularly important in this context since they

provide detailed consideration of the counter-transference pitfalls

in this kind of treatment. Not only is this worth stressing to the

seasoned therapist, but it highlights a major pitfall that undertrained staff may be subject to, namely, adroit manipulations

whereby staff members come to act out the roles projectively

assigned to them by their patients.

The fourth constituent in a sense brings the prescription for

treatment into full circle. Whatever generalizations have been

advanced, the appreciation of the uniqueness of individuals is sustamed in stressing the necessity for individualized diagnosis and

treatment planning.

Together the present collection of papers is testimony to contemporary theoretical and technical developments which have provided the vehicle for the authors of this monograph to rise to the

challenge of comprehending and providing a sober and realistic

direction for this difficult and many-sided problem. What has

evolved here is not just another would-be panacea but rather the

application of a particular perspective, individually developed,

toward a common goal. The result at this early juncture appears

promising, that a psychodynamic psychology can provide a

powerful tool in the further evolution of training, treatment and

prevention.

REFERENCES

Chein, I., Gerard, D.L., Lee, R.S., and Rosenfeld, E. The Road to H. New

York: Basic Books, 1964.

Fenichel, O. The Psychoanalytic Theory of Neurosis. New York: W. W. Norton,

1945.

Gerard, D.L., and Kornetsky, C. Adolescent opiate addiction: A case study.

Psychiatr Q, 28:367-360, 1954.

Glover, E. On the etiology of drug addiction. In: On the Early Development

of Mind. New York: International Universities Press, 1956.

Hartmann, D. A study of drug taking adolescents. Psychoanal Study Child,

24:384-398, 1969.

Hendin, H. Students on heroin. J Nerv Ment Dis, 158:240-255, 1974.

Khantzian, E.J. A preliminary dynamic formulation of the psychopharmacologic action of methadone. In: Proc. Fourth National Methadone Conference, San Francisco, January 1972.

Opiate addiction: A critique of theory and some implications for

treatment. Am J Psychother, 28:59-70, 1974.

Self selection and progression in drug dependence. Psychiatry Dig,

36:19-22, 1975.
KHANTZIAN AND TREECE: AN OVERVIEW 25

Krystal, H., and Raskin, H.A. Drug Dependence. Aspects of Ego Functions.

Detroit: Wayne State University Press, 1970.

Milkman, H., and Frosch, W.A. On the preferential abuse of heroin and amphetamine. J Nerv Ment Dis, 156:242-248, 1973.

Radford, P., Wiseberg, S., and Yorke, C. A study of “main line” heroin addiction. Psychoanal Study Child, 27:156-180, 1972.

Rado, S. The psychoanalysis of pharmacothymia. Psychoanal Q, 2:1, 1933.

Narcotic bondage. A general theory of the dependence on narcotic

drugs. Am J Psychiat, 114:165, 1957.

Savit, R.A. Extramural psychoanalytic treatment of a case of narcotic addiction. J Am Psychoanal Assoc. 2:494, 1954.

Wieder, H., and Kaplan, E. Drug use in adolescents. Psychoanal Study Child,

24:399, 1969.

Wurmser, L. Methadone and the craving for narcotics: Observations of patients

on methadone maintenance in psychotherapy. In: Proc. Fourth National

Methadone Conference, San Francisco, January 1972.

Psychoanalytic considerations of the etiology of compulsive drug

use. J Amer Psychoanal Assoc, 22:820-843, 1974.

Yorke, C. A critical review of some psychoanalytic literature on drug addiction. Brit J Med Psychol, 43:141, 1970.

Zinberg, N.E. Addiction and ego function. Psychoanal Study Child, 30:567-

588.1975.
CHAPTER 3

Needed: A Theory (An Historical

Perspective)

Herbert Wieder, M.D.

Why, in the presence of a vast amount of data obtained from

clinical experiences, experimental studies, statistical analyses and

research in the basic sciences, has the enigma of drug use not been

more rewardingly clarified? A cursory review of my experiences

extending back to 1946 suggested their presentation to illuminate

an important obstacle to clarification. If some lessons could be

learned from the past and delineated, fresh ideas might be released.

“Even,” as Freud said, “if we cannot see things clearly, we will at

least see clearly what the obstacles are.” (Freud 1926, p. 124).

HISTORICAL REVIEW

Participating in a conference on the application of psychodynamic theory to the treatment of opiate addiction evoked a feeling

of deja vu. In 1946 a group of clinical staff at the former U.S.

Public Health Service Hospital at Lexington, Kentucky, met regularly to discuss the addict patients. Extended over a 3-year period,

these meetings were supplemented by consultative discussions with

psychoanalysts. Although new to this clinical problem, all staff

were eager and energetic.

From the beginning we were confronted by what we came to

learn were the vicissitudes of aggression and libido, deviant ego

development, disturbed object relationships, superego malformation, and psychodynamic conflicts influenced by intoxicants. With

the help of the psychoanalytic literature and consultants, we also

rediscovered observations and conclusions of our predecessors.

26
WIEDER: AN HISTORICAL PERSPECTIVE 2 7

Since we were studying addicts, we thought our findings related to

narcotic addicts in particular. We were gradually disabused by the

recognition that after detoxification, addicts were people demonstrating the whole gamut of non-addict psychopathology (Kolb and

Himmelsbach 1938; Pescor 1939).

However, we did query and speculate on the applicability of our

findings to treatment rationale. This led to devising what were considered innovative approaches in those days. Later in the 1960’s

many of the same proposals were rediscovered by others to reappear on the scene as “new” modalities. For example, external

“support of the superego” represented by Kentucky’s so called Blue

Grass Law was one. Similar to it was New York State’s later voluntary incarceration in lieu of conviction; prolonged hospitalization at

Lexington as an “ego support for dependency needs” was advised;

group and individual psychotherapy were encouraged; a pilot Narcotics Anonymous, a spin-off from Alcoholics Anonymous under

the aegis of the Salvation Army, was a forerunner to Synanon; different modes of detoxification were explored; confrontation groups

were formed. All of these therapeutic plans derived from the application of implications from psychodynamics to the treatment of

drug addicts.

Each approach in time returned minimal gains. The inapplicability of a mass-scale approach, as if addiction were a unitary syndrome, became apparent. The inappropriateness of prescribing

treatment for symptoms of indeterminate etiology surfaced. The

dismal specter of relapse underscored our ineffectiveness in helping

patients achieve and maintain a drug-free life. We could explain

neither our therapeutic impotence nor our successes because we

weren’t clear about what we were treating.

Most everyone knew that only after detoxification did the therapeutic struggle for sober, mental equilibrium begin. Therapy, however, could be no more sophisticated, innovative, or successful for

these patients specifically than for the general psychiatric population without drug use symptomatology. In addition, the only

special treatment unique to drug addiction was the process of

detoxification. This is equally true today.

The absence of experienced and analytically sophisticated psychiatrists, who might have reformulated simplistic and illusory premises, handicapped the therapeutic aspect of Lexington’s function.

Although psychoanalytic treatment itself was not particularly indicated, rather, a sound psychoanalytic viewpoint was needed to

orient the conceptualization of drug use in the spectrum of human

behavior and to unify the avalanche of research findings.

Insight into the deeper questions of why drugs existed in a per-
2 8 PSYCHODYNAMICS OF DRUG DEPENDENCE

son’s life was needed. Toward that end the U.S. Public Health Service would have underwritten analytic training for suitable personnel

willing to remain in the Service. That program did not materialize.

Unfortunately, and unjustly, Lexington’s therapeutic failures became more of public and medical world knowledge than did important research and observational contributions, which were often

unnoticed.

The research department had the advantage of a Governmental

mandate to conduct basic and original research into narcotic addiction. In those days “narcotic” was a legal term as much as a pharmacological one. All substances subject to control by the Bureau of

Narcotics were loosely called narcotics, and possession or use was

considered a narcotic violation. The confusion and equation of legal

and pharmacologic terms became fixed in the public’s mind. For

the-first time pharmacology, neurophysiology, neuropharmacology,

experimental neurology, biochemistry and-what would nowadays

be difficult-human experimentation were brought to bear on the

phenomenology of drug use.

Objective evidence, as contrasted to widely divergent clinical

opinions, personal attitudes, and mythology, about drugs and users

was obtained. Much of the data is still valid and must be integrated,

not ignored, into present-day thinking concerning drug use.

From the physiological, pharmacological, and clinical psychiatric investigations a wealth of information was garnered. For example: The abstinence syndrome of opiates was documented and

classified; physical dependence and tolerance were demonstrated as

consequences of habitual use and not the causes of, or synonyms

for, addiction. In the attempt to define “addiction,” however, the

researchers somewhat arbitrarily decided that the presence of

physical dependence was a necessary concomitant for a user to be

considered “addicted” to an opiate. The criterion, physical dependence, was incorporated into a general definition of “addiction,”

“addictive” and “addicted” and led to many of the prevailing difficulties in conceptualizing and defining drugs and their use. It

posed the puzzle, for example: Is an addict who has been detoxified

still an addict?

This restricted definition of addiction was a concept too narrow

to be applied to the broad spectrum of use, drugs, and users that

came to light. Isbell was still at work on a definition in 1970. As an

internist, he had recognized early what most psychologically

minded researchers later came to believe, namely, that addiction

was best conceived as a kind of compulsion to alter a state of mind,

not a physical state exemplified by physical dependence (Isbell and
WIEDER: AN HISTORICAL PERSPECTIVE 2 9

Chrusciel 1970). The observation that drugs are not indiscriminately

chosen or freely interchangeable contradicted a commonly held belief. Left to freedom of choice, users establish a “drug of choice,”

or preference. Together with Kaplan in 1969, I reported on this

phenomenon. Drug free did not mean cured or healthy; physical

dependence especially in the younger age groups did not necessarily

augur the severe psychopathology characteristic of the older,

chronic user (Wieder and Kaplan 1969). These emerging distinctions

were ill-served by a definition of addiction restricted to physical

dependence.

Marihuana users did not fit the concept of addiction which

stressed physiological concomitants along with a compulsion (Kolb

1938). Marihuana habitues were different from morphinists, and

most of the former did not even use opiates occasionally (Pescor

1943). The U.S. Public Health Service argued for decrimininalization of marihuana in 1947 because neither the users nor the substance conformed to the working definition of addict or addiction;

nor for that matter did cocaine, mescaline, and other substances.

The close causal connection that was believed to exist between

crime and use of drugs was disproved along with the myth of

marihuana as the steppingstone to heroin. However, even when

these points were aired by the “President’s Commission on Crime,”

they were not widely accepted. The disavowal of myth-puncturing

data was, and still is, evident. Questions remained. How was use of

marihuana and other substances to fit into the concept of drug

addiction? Where did alcohol and alcoholism fit?

Very few opiate addicts voluntarily coming off the street demonstrated strong signs of an objective abstinence syndrome (Kolb and

Himmelsbach 1938). On the other hand, many who used barbiturates to supplement their drug need developed severe, sometimes

fatal reactions to their hospitalization, before the barbiturate

abstinence syndrome was recognized.

Further Lexington contributions established how to detoxify,

and the need to confirm the presence of physical dependency before detoxification. Methadone research and clinical trials on our

withdrawal service developed methadone’s status as an agent

superior to morphine for detoxification from opiates. The research

division also predicted the chaos that has now occurred if methadone were not considered as equivalent to morphine in its effects

and consequences (Isbell et al. 1947).

The amount of data did not receive the wide acceptance they

deserved. Lexington was producing objective evidence and was

being ignored or repudiated by clinical impressionists. I reported on
3 0 PSYCHODYNAMICS OF DRUG DEPENDENCE

two contradictions to clinical impressions. Demerol was proclaimed

in clinical medicine as non-addicting, except to people who had

abused morphine. Even after reporting (Wieder 1946) addiction of

the first few primary Demerol users the myth of its non-addicting

quality remained. A second report (Wieder 1949) repudiated insulin

as a safe, good treatment for the abstinence syndrome, an example

of a treatment elaboration based on unconfirmed clinical impressions. (Insulin therapy of schizophrenia had been developed by

Sakel [1930] on the basis of the good results he thought he had

observed in the treatment of the abstinence syndrome.) A later,

more current example in my judgment is the misuse of methadone

for maintenance, based on illusory premises and ignoring the implication of its interchangeability with opiates (Dole and Nyswander

1965).

The need for rigorous controls in the study of drug use and users

was ignored by many. As one small example, many people believed

they could detoxify a physically dependent user on an open ward.

All of the observational safeguards necessary to demonstrate physical dependence (Kolb and Himmelsbach 1938) during the first 36

hours of hospitalization were ignored. Therefore the efficacy of a

detoxification procedure could not even be demonstrated as needed.

No therapeutic program for drug-using patients can be assessed

without strict safeguards.

But with all its data, Lexington could not formulate psychologically true definitions or a theory of addiction that could apply to

the total scene of man’s involvement with drugs. Lexington’s imprint on the thinking about the problem remained consistent with

a medical model of illness.

Apart from its paucity and deficiencies in the type of data Lexington was developing, the psychoanalytic and psychiatric literature prior to 1960 was limited in scope by the (N.B. upper class)

socioeconomic type and small number of patients treated and

reported (see Bibliography). Drug addiction was predominantly

viewed as an impulse disorder and implicitly referred to opiates.

Though the analytic reports were informative, the formulations and

psychodynamics described could have been applied to many who

were not addicts. Importantly, however, many who reported cases

would draw attention to phenomenology of non-drug-using patients

who behaved toward objects, food, love, fetishes, and tobacco, for

example, “like drug addicts.” Freud had once said that masturbation was the first addiction, and all others were substitutes for it

(Freud 1897). This may be partially true, but the total dynamics

are more complex.

Although the symptom of drug taking, ranging from benign to
WIEDER: AN HISTORICAL PERSPECTIVE 3 1

malignant, occurs in patients belonging to all categories of psychiatric classification, analysts maintained a unitary view of drug

addiction as a special syndrome. “Addiction” or “addict” meant

morphinist; morphinist meant addict, and therefore refractory to

analysis. Very few people understood that of all the forms of drug

use, use of opiates was the least prevalent, though perhaps the most

dramatic and publicized. No encompassing theory of addiction or

drug use was developed by the analysts, even though Rado’s paper

of 1933, addressed to the fundamental questions of what is an

addict and why do people use drugs, was a promising start (Rado

1933). While Lexington staff suffered from an absence of psychoanalytic perspectives, the psychoanalysts suffered from an absence

of comprehensive, objective clinical data.

Rado’s insight that “not the toxic agent but the impulse to use

it is what makes an addict of a given person” (1933. p.2) attempted

to redress the distortion of viewpoint that the drug “took” the

person. Freud, before Rado, had expressed the notion that some

peculiarity in the user accounts for addiction. The insights lay

dormant until rediscovered in the 1950’s and 1960’s when social

alarm refocused analytic thinking onto drug users (Savitt 1963).

Rado’s insight could have been the cornerstone for a theory in the

1930’s. It is the necessary starting point. I believe any theory that

ignores that insight and its implications will be inadequate and will

permit the perpetuation of confusion in conceptualization.

In the 1950’s drug use seemed to erupt on an international scale,

forcing clinical attention upon psychiatrists and psychoanalysts

with little but their own limited experience and education in the

drug scene. The model of adult opiate addicts and their refractoriness to psychoanalytic treatment dominated professional thinking,

and few people wanted to treat drug-using patients. At the same

time sociologists, educators, psychologists, penologists, clergymen,

and opportunists exploded on the scene with their own brands of

cure and salvation. Though much of this furor could be seen as the

anxious cries of a threatened and uninformed society, confusion

was rampant among the professionals. At that time psychoanalysis

and psychiatry had lost whatever prestige they had in this area by

default. Because of the disappointment of unrealistic therapeutic

expectations the public harbored and the realistic ignorance which

they professed, by their disinterest in treating drug-using patients

psychiatrists and analysts were viewed as just another source of

unhelpful opinion.

I refer you to the “Conferences on Drug Addiction Among

Adolescents” (1953) held at the New York Academy of Medicine

in 1951 and 1952. These conferences were called to meet the emer-
3 2 PSYCHODYNAMICS OF DRUG DEPENDENCE

gency of “drug addicts loose in New York City”-an alarm that had

been sounded in a 1921 conference and again in the 1960’s. Wild

estimates ranging from 2,000 to 250,000 appear often and with the

flimsiest basis of demonstrable evidence. A host of talented and

experienced people from various disciplinessociology, penology,

psychiatry, public health-met and presented their data in familiar

sounding terminology. However, each discipline had its own set of

meanings and definitions. Those who represented the legal professions viewed addiction as a criminal act; for them a drug was a drug

only if the substance was prohibited by the law. For sociologists,

addiction was an illness produced by availability of substances in

the context of socioeconomic factors. Psychiatrists described addiction as the consequence of an impulse disorder. Everyone’s aim was

to “cure,” meaning to “stamp out drugs.” No collaborative effort

was possible, each discipline vying for dominance, and no psychological base to unify the findings could be proposed.

WHAT IS NEEDED

The same lack of definition persists in the present. Everyone has

his own idea about the problem and will continue to perpetuate

confusion unless areas of agreement are found for formulations.

A working theory should encompass what has been clinically and

experimentally confirmed, explain a good deal, and have some predictive reliability. Such a theory would have precluded, among

other things, excessive governmental expenditures on poorly conceived programs whose failures were predictable. Theory would also

facilitate better diagnostic discrimination for the rational prescription of available treatment modalities.

A Panel (1975) at the American Psychoanalytic Association disseminated drug-related clinical experiences and observations in

research projects. Levels of experience and sophistication were

widely disparate, and the infrequency of meetings prevented developing a cohesive accumulation of theory and experience.

Results of a study group of the Association for Child Analysis

were reported by Dora Hartmann (1969). A group of child analysts

studying drug-using adolescents experienced difficulties at the onset

by a confusion of terminology and orientation. A profitable year

studying cases ended up rediscovering much that was already

known. Modifications of therapeutic technique, however, were

determined by the dynamic and diagnostic considerations of each

case. Reasonable successes were achieved with some.

Rediscovery is certainly at times valuable; for many it is educa-
WIEDER: AN HISTORICAL PERSPECTIVE 3 3

tional or confirmatory of past data. But it can also become an endless repetition. It is my belief that we are less in need of data than

of a systematic examination of what is available.

From the mass of data extant, some formulations based on psychoanalytic concepts could and should be tentatively structured,

initiating a common language. The problem of definition, terminology, conceptualization, and theory formation is central to our

inability to penetrate the enigma. As things stand now, everyone

has his own theory, and that is as good as none. All statistics, proposals, claims and counterclaims should be reviewed from a base of

unified, realistic definition.

Kaplan and I (1969, 1971) have offered such a tentative set of

formulations, derived from a study in depth of the drug of choice

phenomenon, which are explanatory and predictive. Definitions of

“drug” and “use” and terminology for classification of users are

consistent with psychoanalytic concepts. Our theory and formulations are in accord with psychoanalytic hypotheses, the clinical

scene, and the overall human behavior with drugs. Formulations

applicable to all phases of life place drug use into the spectrum of

human behavior from so-called normal to pathological. We claim

no preemption of a theory with our contribution. However, it may

be viewed as a working model of what a group of analysts could

collaboratively derive.

The aim of finding practical application of theory to the treatment of opiate addiction raises a number of questions. Does it

imply that dynamic theory is not currently applied to treatment?

Surely not, since any regimen that could be dignified with the term

“rational therapy” would be devised or prescribed on inferences

from a patient’s psychodynamics and diagnosis. Certainly the analytic literature is replete with examples of modification of therapeutic

technique as a function of a patient’s developmental deviations and

needs (Maenchen 1970; Eissler 1958). Any inferences from psychodynamics as applied to treatment, however, are specific for an individual patient, not generalized for presenting symptomatology per se.

Is narcotic addiction again being singled out as a unitary syndrome, as distinct from symptomatic behavior of diverse etiology?

Is there an implication that psychoanalytic theory would illuminate

homogeneous psychodynamics differentiating opiate addicts from

other chronic drug-using patients? Although a patient’s preferential

use of opium can reveal something about his manner of conflict

solution, we are not informed by that preference of the urgency

with which he seeks it. The use of terms such as “narcotic addiction” and “addict” suggest the persistent presence of a sterotype

image that ignores the spectrum of use and user. If we think there-
3 4 PSYCHODYNAMICS OF DRUG DEPENDENCE

fore that by applying our knowledge of psychodynamics to the

problem of narcotic addiction we improve our therapeutic capabilities, we have a skewed view.

It is inconceivable that a single-minded emphasis in any relevant

discipline will unravel the puzzle. Psychoanalysis, however, offers

the most comprehensive view of human behavior and development,

the most fruitful frame of reference or underlying orientation to tie

data from many disciplines together. As both a contributing collaborator with his own data, and an organizer and synthesizer of

diverse data, the psychoanalyst with his unique viewpoint will contribute most in the area of formulation and theory development.

Before innovative procedures are proposed or programed, serious

attention should first focus on formulating the problem, rigorously

adhering to psychoanalytic concepts. I would propose a multidisciplined “Think Tank,” chaired by a psychoanalyst, to sift, evaluate, and structure different levels of information. With the millions

of dollars wasted on many wild projects in the past, the cost of

such sober reflection would be the least expensive for potentially

rich results, and the most innovative approach in the long run.

When our national crusade on cancer was launched, the British

Government wisely heeded the advice of its chief scientific adviser

and refused to join. His opinion about cancer is equally applicable

to any crusade mounted against the drug crisis: “In my view, any

campaign which sets out to buy a cure for cancer without the most

careful and thorough preliminary long term planning is in danger of

encouraging mediocrity and the routine pursuit of ideas which may

long since have ceased to be fertile” (Zuckerman 1972).

REFERENCES

Conferences on Drug Addiction Among Adolescents. New York: Blakiston

Division, McGraw Hill, 1953.

Dole, V.P., and Nyswander, M. A Medical Treatment for Diacetyl morphine

(Heroin) Addiction. A Clinical Trial with Methadone Hydrochloride.

JAMA. 193:646-650, 1965.

Eissler, K. Notes on Problems of Technique in the Psychoanalytic Treatment of

Adolescents: with Some Remarks on Perversions. Psychoanal Study Child.

13:223-254, 1958.

Freud, S. The Origins of Psycho-analysis. Letters to Wilhelm Fliess, #79. Marie

Bonaparte, Anna Freud, Ernst Kris, eds. New York: Basic Books, 1953.

Freud, S. Inhibition, Symptoms, and Anxiety. SE XX. London: Hogarth Press,

1926, p. 124.

Hartmann, D. A Study of Drug Taking Adolescents. Psychoanal Study Child,

24:384-398, 1969.
WIEDER: AN HISTORICAL PERSPECTIVE 3 5

Isbell, H. et al. Tolerance and Addiction Liability of 6-Dimethylamino-4-4-

Diphenyl-Heptanone-3 (Methadone). JAMA, 135:888-894, 1947.

Isbell, H., and Chrusciel, T.L. Dependence Liability of Non-Narcotic Drugs.

Supplement #43 to Bulletin of WHO, Geneva, 1970.

Kaplan, E.H., and Wieder, H. Drugs Don’t Take People-People Take Drugs.

Secaucus, N.J.: Lyle Stuart, 1974.

Kolb, L. Marijuana. Federal Probation, July 1938.

Kolb, L., and Himmelsbach, C.K. Clinical Studies in Drug Addiction. Am J

Psychiatry, 94:4, 1938.

Kolb, L., and Himmelsbach, C.K. Clinical Studies of Drug Addiction. Supplement #128, Public Health Service Reports, 1938.

Maenchen, A. On the Technique of Child Analysis in Relation to Stages of

Development. Psychoanal Study Child, 25:175-200, 1970.

Pescor, M.J. The Kolb Classification of Drug Addicts. Supplement #155, Public

Health Service Reports, 1939.

Pescor, M.J. A Statistical Analysis of the Clinical Records of Hospitalized Drug

Addicts. Supplement #143, Public Health Service Reports, 1943.

Rado, S. The Psychoanalysis of Pharmacothymia (Drug Addiction) 1. The

Clinical Picture. Psychoanal Q, Vol II, No. l:l-23, 1933.

Sakel, M. Theorie der Sucht. Zeitschrift fur den gesamelten Neurologische u.

Psychologische. 129:639, 1930.

Savitt, R.A. Psychoanalytic Studies on Addiction, Ego Structure in Narcotic

Addiction. Psychoanal Q, 32:43-57, 1963.

Wieder, H. Addiction to Meperidine Hydrochloride (Demerol Hydrochloride).

JAMA, 132:1066-1068, 1946.

Wieder, H. Objective Evaluation of Insulin Therapy of the Morphine Abstinence

Syndrome. J Nerv Ment Dis. Vol. 110, 1:26-35, 1949.

Wieder, H., and Kaplan, E.H. Drug Use in Adolescents. Psychodynamic Meaning and Pharmacogenic Effect. Psychoanal Study Child, 24:399-431, 1969.

Zuckerman, Lord Solly. Cancer Research. Science, 178:1184, 1972.
CHAPTER 4

Mr. Pecksniff’s Horse?

(Psychodynamics in Compulsive

Drug Use)

Leon Wurmser, M.D.

I would like to thank the research staff at the National Institute

on Drug Abuse for opening a potentially fruitful and important dialogue with members of the psychoanalytic community who have

worked intensively and extensively with compulsive drug users.

Since this topic also forms the core of a book I have just completed, I decided I would do most justice by selecting a few pertinent excerpts from that work for presentation here. For brevity, I

leave out supporting evidence and most of the broad theoretical

implications. All of that will be published in, I hope, quite exhaustive form.l

Here, the major and encompassing ideas underlying the investigation will be summarized; a brief description of some psychodynamic findings will follow, leading to several recommendations.

Since even this adumbrated presentation is somewhat lengthy, the

following title outline may help the reader:

THE SHIFT IN FOCUS

ANALYSIS OF THE DIRECT ANTECEDENTS

The Vicious Circle

Affect Regression and Breakdown of Affect Defense

The Search for an Affect Defense

Splitting

Externalization-The Neglected Defense

Summary of the Direct Antecedents

SOME COMMENTS ABOUT PREDISPOSITION

TREATMENT

Psychotherapy

Large-scale Treatment Policy

1Copyright © 1977 by Jason Aronson. All rights reserved.

36
WURMSER: MR. PECKSNIFF’S HORSE? 3 7

THE SHIFT IN FOCUS

The starting point of my reevaluation of some of the common

preconceptions about compulsive drug users in general and narcotic

addicts in particular was the following distressing experience, repeated many times over the last 12 years since I started working

intensively and systematically with all types of what is too loosely

called “drug abuse.”

At first I was provoked by the habits and attitudes of these

patients, feeling that I was dealing indeed with the scum of mankind, feeling anger about being lied to and manipulated, feeling

scorn for their flaunting of being “high” and their flouting of all

efforts to help them and of all rules we live by.

Yet the more I got to know them, anger, disdain, frustration

vanished, and a deep sense of despair and pity broke through. I

could hardly find better words than what Faust said entering the

dungeons where Margarete was awaiting the dawn and her execution, his almost untranslatable: “The whole depth of human misery

grips me” (“Der Menschheit ganzer Jammer fasst mich an”). Often

I felt a sense of helplessness, a wish to help, and an ignorance of

how to help. The problems of drugs, drug effects, drug prohibition

receded, paled compared with the overwhelming problems posed by

these patients who sought help, were forced to be treated, fled from

help, died.

When I followed the literature, the discussions at scientific conventions, the opinions expressed by friends, in audiences, by

lawyers, no suggestions, no help were offered. A vast terra incognita

was lying before me, covered by such expressions as: “They are just

sociopaths!” or “They are not motivated,” “the living dead,” “the

dope fiends.” Thus the problem posed itself with glaring sharpness:

How can drug abuse be understood from the context of the individual’s life experience, from his wishes and fears, from his deficiencies

and efficiencies, from his conflicts in past and present-in short,

from a psychological point of view. How can these deeper problems

be treated?

Thus on the one side we have a relative plethora of pharmacological studies and sociological inquiries, although I do not imply these

are redundant, and much more work in these fields should be done.

Moreover, the politics and the legal aspects of illegal drug use fill

the columns of our newspapers and tax the exegetical skills of selfstyled experts of all kinds: lawyers, politicians, policemen and

administrators. Many deal seriously and compassionately with the

problems, many others make cheap hay from them, but most skim

just the surface.
3 8 PSYCHODYNAMICS OF DRUG DEPENDENCE

On the other side, drug abuse has remained off the beaten track,

where many psychiatric and psychological explorers will not tread.

There are good reasons for this: one is precisely the complexity of

the problem, namely that psychological factors are so tightly interwoven with sociological, economic, political, and legal factors.

Where the values of power, expediency, public success, and cost

efficiency are uppermost, the required strategies of manipulation

and control become so intermingled with therapeutic considerations

that the value of insight, inner change and control, and the methods

of introspection and empathy, have perforce to take a back seat.

Yet, in all these years that I have consistently devoted a large part

of my professional work to these patients I have been struck by this

overriding impression: that severe psychopathology was a preexisting condition in those people for whom “drug abuse” became a real

problem; that these inner problems were indeed of crucial explanatory importance.

At the same time I noticed resistance against this view, resistance

of different content, from different walks of life, of various intensity and origin. Medical colleagues frowned upon it. Psychiatrists

doubted it. Even some psychoanalytic friends felt I exaggerated the

role of intrapsychic and family problems as compared with social,

cultural and political influences. My co-workers in the drug abuse

programs were often quite negative about recognizing the psychological problems andsometimes with some derision-emphasized

instead the value of manipulation and exhortation in the form of

counseling, the value of external change. The patients themselves

very often-though by no means always-put their problems on

friends, “bad environment,” “curiosity” and “society.” Their

families regularly did, nearly without fail.

A large role in this negation is played by an antipsychiatric bias

on many levels, a prejudice against looking at one’s inner life (problems or potentialities), at times so strong that we might call it

“psychophobia’‘-a deep-seated fear of taking emotional factors

seriously, a denial of the importance of emotional conflict, which

haunts drug abusers as well as those dealing with it.

Thus, I decided to collect as much evidence for the importance

of psychopathology as I could muster and put it in a reasonable perspective. Obviously many other factorssocial, cultural, etc.-are

involved, cannot be neglected, have to be weighed, put in relation

to the rather crushing weight of personal clinical experience.

This leads to a rather radical refocusing which has only a few

precedents, mainly, the work of Krystal and Raskin, Wieder and

Kaplan, Khantzian, Frosch.
WURMSER: MR. PECKSNIFF’S HORSE? 3 9

These reformulations can be summarized in the following five

points:

(1) The focus of inquiry and intervention is shifted from drugs

to personality, from drug use as a social phenomenon which might

be relatively easily manipulated, deterred, cured by external means

(such as threats, counseling, laws and jails), to drug use as a symptom of a psychological depth dimension which has been up to now

only rarely investigated or treated. This implies that psychoanalysis

and psychotherapy have to contribute a vastly neglected component

to the study and treatment of this mass phenomenon.

At a time when both psychoanalysis and psychiatry are under

fire for being irrelevant, moribund or dead, this study is grounded

in the psychoanalytic process of inquiry in regard to both observation and abstraction. Hence it is no part of the current stampede to

get “nothing but Facts . . . imperial gallons of facts,” the flight

from theoretical constructions and hierarchies of abstractions. Nor

does it take any theory as dogma, as more than a form of symbolic

representation. Symbols are not facts, but ways to order themindispensable, but on a different plane of understanding.

(2) Yet this reorientation does not lead to a one-way street.

Rather, psychoanalysis as theory may in turn benefit from new

observations gained in this field. Therefore, the investigation underlying this brief essay, by examining in depth a number of individual

cases, tries to deepen, to question and to enlarge some common

(and a few less common) psychoanalytic and psychiatric concepts.

For example, the phenomena and theories of narcissism and aggression are reevaluated in the light of these experiences. The defense

“mechanisms” of denial and externalization and the problems of

splitting are examined. Such investigation may lead to a deeper

understanding of the quite complex nature of “simple” defense

mechanisms and eventually to a hierarchical ordering of them. At

the same time these defense mechanisms have to be viewed as

patterns of drive gratification, as cognitive forms and basic elements

of symbolization, and as fundamental action patterns. [In addition

to new thoughts about forms of defense, the book at large, though

not this excerpt, attempts, perhaps most importantly, to reexamine

the concept of boundaries and limits, a notion which proves to be

crucial for an understanding of these patients, and attempts to integrate the concept more solidly with current psychoanalytic theory.]

Throughout, the affects of guilt and shame, and their archaic precursors, have proven to be of special help for deeper understanding.

(3) By merely differentiating non-intensive from heavy drug use,

the sociolegal definition of drug abuse is woefully inadequate for a
4 0 PSYCHODYNAMICS OF DRUG DEPENDENCE

psychotherapeutic approach. Instead, the concept of compulsiveness is chosen as operationally most meaningful, both for this particular field and for psychopathology in general. It serves as the criterion for “emotionally sick,” as proposed by Kubie, not primarily

to adjudge whole persons, but single mental acts. To select this

specific “elementary particle” as criterion, with its practical, theoretical and axiological implications, appears especially useful and

fulfils the crucial criteria for scientific knowledge as set down by

Cassirer (1958).

Moreover, compulsiveness emerges as a relative property of

mental processes: acts (thoughts, feelings, actions etc., and their

sequences and patterns) may be more or less compulsive, varying

from person to person, and within an individual from time to time;

acts felt to be absolutely compulsive or absolutely free either do

not occur at all or are very rare, Since it is to a large extent observable, this criterion may prove to be particularly helpful for research.

(4) Since drug abuse always involves pharmacological and social

factors, it is strategically placed on the crossroads of psychoanalysis

and pharmacology, of somatic medicine and general psychiatry.

Indeed, the long shadow of drug abuse in human history lies across

the crossroads of sociology and politics, of history and philosophy,

even of literature and anthropology.

No look at the “hidden dimension” of drug abuse psychodynamics can fail to notice the connections between leading underlying

problems in the individual (and this holds true not merely for the

drug use itself) and sociocultural and philosophical antitheses, conflicts, contradictions. In a more comprehensive study than presented here much thought will therefore have to be devoted to

tracing such lines from the individual to the surrounding circles of

etiology, no matter how unspecific such connections remain.

Of particular importance among these connecting threads is the

one between various aspects of the superego and axiology. The

pathology of ideal formation in compulsive drug abusers reflects a

deeper, more general “betrayal of philosophy.” Again, there may be

mutual illumination between the psychoanalysis of the superego

and value philosophical conflicts and hierarchies.

More concretely this leads inevitably into considerations of ethics

and legal philosophy. The experiences garnered in psychoanalytic

and psychotherapeutic work cast new light on many central questions of these two philosophical fields and hence on the practice of

legislation and law enforcement as well.

The psychoanalyst is in a delicate position: she/he cannot advocate specific ethical values; but has to remain, even in clinical work,

primarily a scientist who is beholden to one leading value system,
WURMSER: MR. PECKSNIFF'S HORSE? 4 1

viz. that inherent in every scientific method. Yet, as this system

applies to psychoanalytic values (integration, freedom of compulsions, integrity and honesty etc.), it has ineluctable effects upon

specific decisions of an ethical nature. His central value system is

beyond ethics in a narrow sense, but not beyond value philosophy.

It also has a most profound influence on ethics, probably as no

other area of scientific inquiry.

(5) From all this it becomes obvious that there are, on no level,

any simple, quick, easy solutions. The answers to many of the

questions lie at this time still out of reach. Glib “either-or” reactions inevitably founder on this complexity.

An implication of this complexity is that in no case of severe

drug use will one form of treatment suffice. It is typical (quite

similar to severe chronic physical illnesses, like leukemia or tuberculosis) that one method of therapy is not enough, that four to seven

(or more) “modalities” may have to be employed, concomitantly or

sequentially. It is not at all rare that a therapeutic advance becomes

possible only when individual- , group- and family-therapy are combined and often supported by medication or hospitalization, and

vocational (and other forms of social) counseling.

The “one-track mentality” is very common and often a cardinal

error in the treatment of these patients. Still, even a modality orientation does not do justice to the complexity and quite often may

prove disastrous. Not only may it impede the tackling of a patient’s

severe inner problems, but it may exacerbate a severe “pathology”

of treatment programs and systems themselves. In the administration of such programs one often witnesses an “insolence of office,”

a kind of pathology from people expected to treat it. Further, from

insufficient command of complexity, treatment is often “penny

wise and pound foolish.” By saving in the short run, expenditures

grow in the long run massively and outrageously, manifested, for

example, in enormous costs of crimes committed by compulsive

drug users and due, I believe, mostly to irrational approaches to

their problems.

Even individual psychotherapy needs new methods, new parameters, to cope with the peculiar problems of this important group of

patients. Conventional psychoanalysis quickly runs into insurmountable difficulties. At the same time some of the basic conditions of psychoanalysis (analysis of transference, countertransference, resistance) remain indispensable.

Recommendations made on the basis of recognizing this hidden,

often negated or circumvented issue of compulsive drug use may

strike many as revolutionary or puzzling-by those who have not

struggled themselves with these patients’ problems for many years,
4 2 PSYCHODYNAMICS OF DRUG DEPENDENCE

who have not been burned many times trying to build up programs,

for them, and who have not been called to help by the families of

these patients in despair.

Yet I consider this type of effort very important. A considerable

proportion of the population in our culture is involved in mild or

severe forms of drug abuse: it may be one-fourth to more than half

of the population. Of these, a very large proportion is undoubtedly

involved in compulsive forms of drug use (at least between 5 and 10

percent of the population in Western countries) if we include, as we

must, alcohol. Therefore, systematic in-depth studies should be con,

sidered with the seriousness a social and health problem of such

magnitude demands, a problem probably affecting far more people

than schizophrenia or most forms of somatic illness.

In addition, the social consequences of this symptom are enormous-another dimension, dealt with by a legal system as ill-suited to

deal with -the problem as with plague, cholera or depressions.

I hear a loud protest, “You use a medical model; how inappropriate!” My answer is, “Yes, it is primarily a problem of illness and

medicine, and more specifically of psychopathology and therefore

of psychiatry and psychoanalysis. Logically and historically this

makes more sense than any other current claim. It is the only

approach which is both humane, seeing and treating this illness like

all others, as part of the human condition, and still takes it very

seriously-not merely as a social and legal deviance nor as a part of

politics and economics, dehumanized to some statistics, nor as a

part of physiology, magically overcome by some enzyme repairs

and powerful potions.” We ought to condemn less and try to understand more.

ANALYSIS OF THE DIRECT ANTECEDENTS

The Vicious Circle

Before the beginning of compulsive drug use, there are clear signs

of a serious emotional disorder, one which may be called “the

addictive illness” or the signs for an addictive career. We are confronted with the very difficult question how to analyze this complex of phenomena leading to the overt outbreak of the illness. This

outbreak especially takes the form of compulsive drug use, but is

not always restricted to this symptom. A few equivalents to drug

dependency which precede or replace this symptom can be observed

repeatedly (violence, other forms of criminality, depression, anxiety

attacks, eating disturbances).
WURMSER: MR. PECKSNIFF'S HORSE? 4 3

The following distinctions emerge: a) A horizontal plane (“what

goes on in the here and now when I start taking drugs for inner

needs”) should be distinguished from what we glean from the vertical plane, which includes the history, the depth dimension, the predisposition. b) Even on this horizontal level, however, we clearly

can distinguish that there are covert events which gradually emerge

in detailed probing beneath the overt phenomena; these covert

processes are partly preconscious and relatively easily retrievable,

partly unconscious and, due to the particular difficulties of psychotherapy or psychoanalysis with these patients, almost inaccessible.

c) The conscious and preconscious processes can, without undue

problems, be arranged in a fairly regular sequence, a vicious circle,

which will be presently outlined. This vicious circle has, as all psychopathology to some extent, a particularly strong self-perpetuating quality, a feeding on itself. d) When we explore the underlying

dynamics of the single elements of such a cycle, we discover that all

of them are themselves already compromise formations, partial conflict solutions. The entire vicious circle thus presents itself as a

complex series of compromise solutions, e) Next we need to recognize and define distinctly the underlying constituent components:

What exactly are the unconscious impulses, wishes, drive components? What exactly are the defenses? How do the defenses themselves reflect instinctual processes? And: What are structural defects

-neither defense nor instinctual drive? f) In answering some of

these questions we get onto very slippery terrain and are in danger

of sliding into pseudoexplanatory concepts. We come face to face

with something which Roy Schafer (1968) rightly complained

about: “. . . many of the familiar descriptive and explanatory terms

of psychoanalysis are global terms, and, if used without further

specification and qualification, they limit or distort perception and

conceptualization of the phenomena” (p. 100). The notions of narcissism, denial, splitting, aggression proved to become names that

were called by Szasz (1957) “panchresta,” catch-all terms, too

broad, playing into the need for complaisance and a sense of knowledge, but becoming imprecise, even contradictory cliches. At the

same time they could not be discarded by any means. They are, as

the term “panchreston” connotes, overly general, they need further

specifications, redefinitions, and occasionally new contents. At

times the attempts to do this are provisional first trials at differentiating what seems well covered with the broad notions.

But to start we have to examine the more overt, less arcane

vicious circle which is accessible to any careful (“microscopic”)

inspection. To illustrate, I use the near verbatim account by a

patient of how he experienced his going to the Bowery at age 19
4 4 PSYCHODYNAMICS OF DRUG DEPENDENCE

and getting drunk, and how this was identical with many events

with alcohol before, with drugs later on, a sequence which I could

witness as well right in the sessions.

(1) It starts out with “any big event-whether I succeed or I fail;

it has the same aftermath: sadness, letdown, loneliness.” In all

patients it is some form of disappointment-realistic or in fantasy,

a letdown from an expectation which may be justified or, more

often, vastly exaggerated, an expectation usually of one’s own

grandeur, far less commonly a disappointment about someone else.

This sudden plummeting of self-esteem is best called a narcissistic

crisis.

(2) The next step is that the feelings become overwhelming,

global, archaic, physically felt, cannot be articulated in words. “I

feel a foreign power in me which I cannot name; all barriers are

gone.” The patients describe an uncontrollable, intense sense of

rage or shame or despair, etc. This is clearly an affect regression

and brings a generalization and totalization of these very archaic,

often preverbal affects (cf. especially Krystal). It is a breakdown of

affect defense.

(3) What happens next is least clear. The affect disappears; only a

vague, but unbearable tension remains; there may be a longing, a

frantic search for excitement and relief, a sense of aimless, intolerable restlessness, a craving (not unlike the one later seen in acute

withdrawal). Instead of the prior feeling we hear: “I thought about

myself as something else, as an object, as a character in a book, that

I was creating the story about myself, a novel. I am not even

actually aware of the pain anymore; it is not you, it is a character in

a book you are creating. My whole life is so: a part who acts and a

part who observes.” The intellectual, observing part is not really

alive, the acting one lives. Like Alexander the Great comparing

Achilles with Homer, our patient states: “It is better to be the

character than to write about him in a novel”-better to act than to

observe. It is important for us to notice the split, reminiscent of the

one observed in severe states of depersonalization. This splitting

recurs in many forms in our patients. In the passage just quoted it is

between observing (and controlling) versus acting in a particular

way, which we shall study shortly. More typically it is between the

most troublesome feelings held down, suppressed, disregarded, the

inner problems in general, and a facade, an illusion of being all

right. Or: the problem lies in the body, outside. I believe the split

necessitates above all a massive denial of inner reality, specifically

of the overwhelming affects. Other defenses—e.g., negation, avoidance, repression and projection-seem to operate as well, but they

pale beside the role of denial in the exact sense: “Disavowal or
WURMSER: MR. PECKSNIFF’S HORSE? 4 5

denial as originally described by Freud involves, not an absence or

distortion of actual perception, but rather a failure to fully appreciate the significance or implications of what is perceived”-especially

of affects (Trunnell and Holt 1974). What is important for us is the

phenomenological evidence of many forms of massive splits,

accompanied by unconscious denial, by an “invalidating fantasy,”

and by a partial acknowledgment.

(4) There is a wild drivenness for action, for seeking an external

concrete solution to the internal (and denied) conflict. “It was unbearable; I had to do something external to change the situation—

no matter what.” Violence, arrest, drugs-the specific modus of this

defense by externalization is actually not even terribly relevant at a

given moment for the patient: the defense by concrete action on

the outside which magically changes life is what counts.

(5) “It was something fascinating when I went to the Bowery.

The position was appealing: to destroy myself, to be a bum. It was

sheer self-destructiveness.” In other moments it was murderous

anger. Again, as Anna Freud and many others observed: aggression,

especially directed against the self, becomes an inevitable link in the

chain. Our paradigmatic case also notes: “I progress, and suddenly I

have the urge to break out, to destroy everything I have built up,

and then I am completely down for a month and slowly build it

(self-esteem, social accomplishment) up again.”

This fifth step is the involvement of aggression, usually by

“breaking out,” transgressing boundaries, violating social limits,

attacking others, destroying oneself, hurting and being hurt, humiliating others and being shamed.

(6) “When despair takes over, the question of honesty becomes

ridiculous.” The drowning man has commonly little regard for

questions of ethics, of integrity. Conscience becomes utterly irrelevant. Trustworthiness, reliability, commitments to others are

acknowledged, and yet made meaningless, treated as if of absolutely

no importance whatsoever. Again I believe there is a profound splitting of the superego, usually accompanied above all by denial, but

also by projection and externalization.

No compulsive drug use (except perhaps for one commonly not

recognized as such, like compulsive smoking) goes without this

superego split.

(7) “When I have broken out, there is so much enjoyment and

excitement, that everything appears okay. I am satisfied then: I feel

sheltered. I am acknowledged: the world owes me a living. I get

something for nothing, and I deserve it.” It is pleasure of many

forms-entitlement above all-which forms the end point of the

cycle.
4 6 PSYCHODYNAMICS OF DRUG DEPENDENCE

Let us summarize what we have found so far: It is a series of conflicts, actuated in an acute crisis, which forms the specific cause.

This specific cause is the following circular constellation: It starts

out 1) with the narcissistic crisis, leading 2) to overwhelming affects,

to an affect regression, a totalization and radicalization of these

feelings. 3) As directed affect defenses the closely related phenomena of splitting (“ego splits”) and fragmentation are deployed:

the defense, mainly in the form of denial, but also of repression and

other “mechanisms,” is carried out partly by psychological means

alone, partly and secondarily by pharmacological propping up

(pharmacogenic defense). 4) Denial requires an additional form of

defense, the element most specific in this series of seven, defense by

externalization, the importance of reasserting magical (narcissistic)

power by external action-including taking magical “things” such as

drugs. 5) This reassertion of power by externalization requires the

use of archaic forms of aggression, of outwardly attacking and selfdestructive forms of sado-masochism. 6) In most cases this is only

possible by a sudden splitting of the superego and other defenses

against superego functions. 7) The final point is the enormous

pleasure and gratification which this complex of compromise solutions of various instinctual drives with various defenses brings about.

Most importantly the acute narcissistic conflict appears resolvedfor the moment. But, as Rado described, the patient is caught in a

vicious circle: “The elation had augmented the ego [now we would

say the self] to gigantic dimensions and had almost eliminated

reality; now just the reverse state appears, sharpened by the contrast. The ego is shrunken, and reality appears exaggerated in its

dimensions” (1933). The patient is not merely back where he

started, but on a yet much lower level of self-esteem.

What I have called “the vicious circle” is represented in the

following model.

It is important to consider the probability that each of the seven

components of the circle is already in itself a compromise formation, a derivative of impulse, defense and defect (or deficiency).

We have to keep this in mind and try to analyze this unconscious

substratum as well. That part is most difficult and uncertain in its

outcome.

Here still another objection will be raised: What is so distinctive

about this League of Seven to make them the culprits in the problem posed? DO we not all undergo narcissistic crises, and are severe

narcissistic disorders not even the daily bread of all psychiatrists
WURMSER: MR. PECKSNIFF’S HORSE? 4 7

THE VICIOUS CIRCLE IN COMPULSIVE DRUG USE

Pleasure 7) 1) Acute Narcissistic Crisis

Superego Split 6) 2) Affect Regression

Aggression Mobilized 5)

and Used

3) Search for Affect Defense

and Use Mainly of Denial

and Splitting

4 )

Externalization as Defense

(by magical power)

and many psychoanalysts? Or to turn to the next objection: he

the internal and external structures and safeguards against these

affects not often in many other people very brittle, just like the

ground around a geyser: apparently firm, but breaking in at smallest

weights and letting the boiling water flood over; is affect regression

not a very common occurrence? And thus we can march down the

list together and eliminate all distinctiveness. It appears to me, and I

cannot be more than hypothetical, that the combination is distinctive. Defective affect defense (of those inner structures that channel

affects, eventually becoming part of the predisposing personality

structure), combines with the two most specific and most important

factors: a) deep-going and labile, rapidly shifting splits, largely resulting from the all-pervasive use of the defense mechanism of

denial, especially against affects, and b) the massive defensive use of

externalization in its characteristic concreteness of action. This

combination in its severity and massivity marks these patients and

sets them apart from all others. This bold claim is based on a careful

comparison in my mind of my toxicomanic patients with a number

of neurotic patients having ostensibly somewhat similar problems

whom I see in analysis, but who have never developed any drug

problems. Whether this specification will hold up, however, only

further comparative scrutiny will show.
4 8 PSYCHODYNAMICS OF DRUG DEPENDENCE

Affect Regression and Breakdown of Affect Defense

This phenomenon which is shared by all toxicomanics and by

many other borderline patients is also described as generalization,

radicalization, totalization of affects, or, as Krystal and Raskin

(1970) did, as dedifferentiation, resomatization, deverbalization.

The terms are ponderous, the facts simple: The feelings become

suddenly and irresistibly overwhelming, fearfully out of control.

Words cannot do justice to them, nor can they be clearly differentiated from each other: Anxiety, anger, despair, pain etc.-all flow

into each other. Henry Krystal (1974) devoted a special and excellent article to this concept, which had been developed by M. Schur

(1953, 1966).

All compulsive drug users have the following affects in common,

which have to be warded off by all means (not only by drugs). All

these feelings are the direct outcome of narcissistic frustration.

Some of them are more prevalent in one type of drug use, others in

another form, but basically they are all there. These basic moods

and affects are: disappointment, disillusionment, rage, shame,

loneliness and a panicky mixture of terror and despair.

In a short survey we can glance at the correlation of specific affects denied, the nature of the narcissistic wish fulfillment attained,

and the preference for certain types of drugs.

(a) The narcotics user has to cope with the emotional pain and

anxiety flowing from the entire array of affects mentioned above.

Among them rage, shame and loneliness seem particularly prominent. What he attains on the side of wish fulfillment is a sense of

protection, warmth and union, of heightened self-esteem and selfcontrol.

(b) The user of barbiturates and other sedatives has to deal with

nearly the same task. Perhaps the feelings of humiliation, shame and

rage are particularly prominent and need the most powerful form of

denial: that contained in estrangement (partial or total depersonalization and derealization). Thus, a study of the barbiturate addict

has to pay particular attention to that peculiar form of compromise

formation; depersonalization is not simply a defense. Particular

wish fulfillments are contained in this symptom and need to be

studied in depth. (However, this does not mean that we shall not

meet in most other toxicomanics hints of this very important symptom, although it is most prominent in the user of hypnotics.)

(c) In psychedelic users the major affects to be denied are the

moods of boredom, emptiness, lack of meaning; from the primary

list too, it is mostly disillusionment and loneliness which is walled

off with the drug’s help. What is attained-s gratification-is a sense
WURMSER: MR. PECKSNIFF'S HORSE? 4 9

of meaning, of value, of admiration and of passive merger—concerning the self as well as ideals.

(d) The users of stimulants, again beyond the primary list, fight

against a particularly intense form of depression, despair, sadness,

loss. Shame about weakness and vulnerability, boredom and emptiness, are quite prominent. The narcissistic gain lies in the feelings of

strength, victory, triumph, invincibility and invulnerability that

reaches in some nearly a manic state. The importance of magical

control, ubiquitous in all categories, is particularly marked in this

group.

(e) Alcoholics are less subject to the primary feelings listed

above; the main feelings denied appear to be guilt and loneliness,

also in many, shyness, shame, social isolation. The narcissistic gratification lies in the expression, not in the denial, of anger which had

been so long suppressed or repressed. In many there is also the feeling of company and togetherness, of shared regression and acceptance in a childlike status, the overcoming of being an outcast, when

alcoholized.

These manifold negative affects break through with unrestrained

force when archaic narcissistic demands are thwarted. Many of

them are already expressions of aggression, the twin brother of narcissism (cf. Freud 1930; Eissler 1971, 1975; Rochlin 1973). In the

section on predisposition the connection of the two will be studied

in a new light.

We have seriously to ask ourselves, however, whether this radicalization and totalization is simply a breakdown of deficient inner

structures, of primitive defenses, or may be in itself a form of defense. Clinical experience with borderline characters (not solely

compulsive drug users) leads me to presume that it can be both:

manifestation of a structural defect as well as a defense.

This becomes clearer when we see how this affect regression

leads to a regressive generalization of perception and cognition. It is

the exaggeration of a correct perception, e.g., itsgeneralization from

one injustice and unfairness or hurt to the whole life. This global

spread, like oil on water, I have often witnessed during sessions.

This affect regression is of central importance for the character

structure of all patients with severe drug problems; and it is a totalization not restricted to some minor areas and choices; it permeates

the whole world view for certain periods, until they can make it

relative again. If they cannot do this, I think we deal with a paranoid deepening of the character pathology already outlined.

Very often it is experienced merely as a vague, but overwhelming

physical tension and restlessness.

This entire phenomenon of affect regression is intertwined with a
5 0 PSYCHODYNAMICS OF DRUG DEPENDENCE

factor of the underlying personality, of the predisposition: the

factor of hyposymbolization, the stunting of symbolic processes

(for a brief note, cf. below). In regard to the question of compromise formation: All this stormy boiling up of affects is an outlet of

regressed instinctual drives, mainly many forms of aggression.

Simultaneously we have already remarked how this “totalization”

serves as a defense, a flight from all too painful, all too limiting,

crushing reality.

The Search for an Affect Defense

This third step is the most difficult to conceptualize. The patient

is, as we saw, overwhelmed and flooded with unmanageable affects

and often also most intense wishes, mostly destructive ones. His

usual defenses have proven deficient. It is here that the drug enters

-as memory or fantasy, then as sought-after means of solution, and

finally as found help and protection, as a discovered coping mechanism (Khantzian et al. 1974).

When Dorian Gray recalled the murder of his (homosexual)

admirer, mentor and father substitute, Basil Hallward, the morning

after, he felt: “It was a thing to be driven out of the mind, to be

drugged with poppies, to be strangled lest it might strangle one

itself.” Many observers have noted that all compulsive drug use is to

be considered an attempt at self-treatment, and that the specific importance of the drug effect can be best explained as an artificial or

surrogate defense against overwhelming affects, at least on a par

with the aspect of wish fulfillment. Moreover it was already noted

that there evidently exists some specificity in the choice of the drug

for this purpose. But then the problems become so difficult and

complex that one is tempted to exclaim with one of Dicken’s characters: “‘Tis a muddle, and that’s aw.” And yet it is perhaps the

most crucial issue to be solved if we want to gain a deeper comprehension of compulsive drug use.

What is the nature of the defenses employed in these patients and

propped up or instituted with the help of the pharmacological

effect? The answer to this question is difficult and complicated.

When we examine the nature and order of defense “mechanisms,”

we should keep in mind what was briefly touched upon earlier—that

the same processes we encounter as defense mechanisms can also

serve as instinctual drive derivatives, as controlling processes of perception and cognition, and as basic action patterns (beyond drivemotivated ones). Moreover we can arrange them in several continua.

These continua stretch from highly differentiated, subtle, usually
WURMSER: MR. PECKSNIFF’S HORSE? 5 1

mostly preconscious-conscious ones, to defenses operating on an

archaic, undifferentiated level, functioning in a state of low integration, of global overinclusiveness, and, as processes, carried by a

most peremptory, i.e., unconscious force. As to the latter I refer to

Kubie’s (1954) and Sandler’s (1969) hypothesis: the more peremptory, compelling, rigid, inflexible, the more pushed by unconscious

motivation (even if the process itself appears on the surface to be

conscious).

Despite the current onslaught against the energy concept in psychoanalytic theory formation I find it, also in this context, a most

useful, albeit metaphorical, one. The defenses on the more mature

end of the continua operate with “neutralized,” sublimated “energies,” those toward the primitive end, are, even experientially, when

analyzed, of quite archaic instinctual, mainly directly aggressive

quality.

I suggest to consider these defenses as lying on four continua:

a. A first continuum, the avoidance type of defenses, stretches

from conscious and preconscious proclamations and wishes:

“I do not want to know” (in Trunnell and Holt’s paper: “denial”

in the vernacular sense: “a ‘declaring’ not to be true”) over

neurotic (unconscious) forms of denial (keeping the affective

significance of perceptions and entire parts of percepts unconscious) and repression (directed against drive derivatives) to

very regressive, much more global forms of denial (of psychotic

or near psychotic proportions).

This first continuum is artificially instituted or, far more

likely, massively reinforced by depressant drugs: narcotics,

hypnotics, minor sedatives and alcohol. The other two types

(psychedelics and stimulants) sometimes support especially

denial, sometimes lift these defenses; their major action lies,

however, in what follows.

Amongst all these defenses lying on the continuum, conscious “disavowal” and massive unconscious denial are by far

the most prominent-immediately prior to drug use and then

part of the drug effect.

Cognitively we find, e.g., the averting of attention versus the

focusing of attention.

b. The second continuum pertains to the dissociation type of

defenses, the breaking of connections. It stretches again from

conscious and preconscious versions, as described by Eissler

(1959) and also in the Glossary (Moore and Fine 1968): conscious isolation in concentrated thinking, the conscious ego split

and superego split in the psychoanalytic situation, to unconscious isolation, and the various forms of splitting accompany-
5 2 PSYCHODYNAMICS OF DRUG DEPENDENCE

ing denial (denial of loss, of castration), to more regressive types

(Kohut’s “vertical” splitting and the limited, partial forms of

fragmentation), and, beyond: to very severe, erratic, labile

forms of dissociation and pervasive splitting, and to the two

most extreme forms of global splitting into all-good and all-bad

and of radical, psychotic fragmentation.

Dissociation’s cognitive usefulness in concentration was commented upon by Freud (1926) and Eissler (1958).

In all compulsive drug users severe forms of splitting and

fragmentation can be encountered. The depressant drugs usually

reduce these dissociations and indeed thus help to synthesize,

whereas particularly the psychedelic drugs massively deepen the

dissociation. Whoever prefers splitting chooses psychedelic

drugs.

c. The third continuum pertains to the action or fight type of

defenses: again from conscious, controlled use (alloplastic

change, creative use of externalization, outright aggression as

defense) to unconscious externalization, turning passive into

active, possibly even identification with the attacker and reaction formation, turning aggression against the self, and magical

undoing, all on various levels of primitiveness. From all these,

archaic forms of externalization will loom up as an omnipresent,

massive form of defense in all compulsive drug users and will be

treated separately. Stimulants are the one category of drugs

which particularly supports the defenses on this continuum,

especially externalization and aggression, turning passive into

active, often in a very primitive form.

d. A fourth continuum of far more cognitive and action-oriented

significance than for defenses is the continuum of the boundary

and limitation type of defenses, stretching again from highly

differentiated and preconscious forms of boundary forming and

limit-setting “mechanisms,” of boundary creation and breaking,

to the most archaic forms of fusion, boundary and limit blurring

and transgressing. Instinctually the continuum reaches from extreme merger to full separateness, cognitively from the archaic

syncretistic thinking (Werner 1948) to full differentiation and

integration (Hartmann, Kris, and Loewenstein 1946; Wynne and

Singer 1963; also cf. Cassirer 1923), in action patterns in

Piaget’s sense, from “original reflex or global schemata” to

schemata based on “generalizing assimilation” and differentiation (cf. Wolff 1960). In regard to the defenses on the one

end we have largely preconscious identifying, learning and

once again externalizing, also conscious detaching, separating

and transgressing, whereas at the more primitive end we would
WURMSER: MR. PECKSNIFF’S HORSE? 5 3

encounter well-known archaic defenses like introjection and

projection, radical idealizing and devaluing, primitive forms of

externalization and identification.

I presume that the placing of one well-known defense “mech-

(e.g., externalization) on several continua is quite justifiable, because the processes contained are often of multiple

significance, and thus, multidetermining. I hold that in all drug

abuse this fourth continuum of defenses (and beyond: of gratification, cognition and action) is used throughout and has

particular importance. Since I presume that all four continua

reach back into earliest childhood, I doubt whether any drug

type by itself evokes a more or less regressive form of defense

“mechanism” (and with that of conflict solution). Usually

severity of preexisting pathology plus massivity of drug effect

(usually dependent upon the dosage and the setting) determines

the depth of regression on each of the four continua.

I do not pretend that I have encompassed all defense “mechanisms.” It is quite conceivable that more forms and different

lines can be found. It appears to me too that, as Hartmann

postulated (Hartmann, Kris, and Loewenstein 1949), all defenses operate mostly with aggressive energies, often in very

archaic, not “neutralized” versions. “. . . It is likely that defense

against the drives (countercathexis) retains an element (fight)

that allows of their description as being mostly fed by one

mode of aggressive energy, and that this mode is not full neutralization” (1955, p. 232). This reference, including the indispensable energy metaphors, is amply demonstrated by the

observations in drug patients: The pharmacogenic deepening of

a defense is blatantly aggressive in nature, the pharmacogenic

lifting unleashes overt conscious forms of aggressive defense

(e.g., conscious disavowal and invalidation, use of direct violence

for defensive purposes).

Thus the very deepening of the major defenses (denial, splitting, externalization) with the help of drugs is an act of destructive aggression, albeit intensely libidinous, especially narcissistic

gains are also attained by the intensification of these defenses:

the very muting of severely disruptive affects itself can lead to

overwhelming feelings of joy, warmth, “good vibes” and, of

course, as we will see in due course, much heightened selfesteem. Patients often become more sociable, friendly, accepting, harmonious, at peace, especially with depressant and psychedelic drugs.

This then leads to the conclusion that again this step, the

pharmacogenic defense, is in truth a compromise formation, in
5 4 PSYCHODYNAMICS OF DRUG DEPENDENCE

these patients, between their major affect defenses (denial, splitting, and externalization) and gratifications of aggression and

libido, in narcissistic and object related forms.

Splitting

When I use the term “splitting,” I shall refer to it in three meanings, largely (though not fully concordant) with Lichtenberg and

Slap’s (1973) distinction: a) as disjunction and fragmentations of

representations, b) in their extreme form as polarization into allgood and all-bad, and c) very importantly, as “splits” in the entire

personality organization, what Schafer (1968), Lichtenberg and

Slap called “pathological intersystemic suborganizations” or “persistent drive-defense-prohibition couplings.”

Lichtenberg and Slap describe these couplings: “. . . manifestations of defensive activity become connected with a specific drive

and with superego structures. . . . Associated with such drivedefense-prohibition couplings are elaborate networks of memories

and displacements. These networks are built around the ideational

contents of the developmental disturbance” (1973, p. 786).

Since these latter theoretical expositions are very abstract and

difficult to understand, I try first to put them into somewhat simpler language: We observe in many, particularly borderline, patients

a kind of “split personality.”

In all forms I consider splitting a defense “mechanism” and the

resultant splits experienced or observed as more complex phenomena, combining the process of splitting with hidden, unconscious

gratifications, and filled with emotional and ideational content.

When we now return to the three radical forms of splitting encountered in all compulsive drug users three features stand out: What I

am most impressed with is the lability of these splits, the steady

shifting of them, the sudden flipflops. Now there is synthesis-now

there is a split. This pertains to feelings, to external limits, to selfimage, the value of others, to ideals and to the conscience (cf. also

Lucy Kirkman’s test results [Wurmser 1977]). It is an utter unreliability of structures, an iridescence of denials and of experienced

and often-described and observed “splits.”

Secondly, these splits are very often covered over by depressants,

exacerbated by stimulants and psychedelics. In the former instance

(use of narcotics, hypnotics, alcohol) they become particularly evident during withdrawal and abstinence.

Thirdly, these splits always involve cognition. At the least it is

what Freud described, the rending of the ego between two func-
WURMSER: MR. PECKSNIFF’S HORSE? 5 5

tions: e.g., the acknowledgment of the standing structures of the

object world and the largely unconscious disavowal of such cognitive entities. Beyond this, in much broader terms, these splits profoundly affect the cognition of objects and self, of time and space,

of all representations of self and object world, of one large part of

the personality versus another massive part.

If we look back over what we have found, especially the prominence of denial and splitting, we are not surprised about the frequency with which these patients describe phenomena of depersonalization and derealization (see above). These twin symptoms occur

either spontaneously or pharmacogenically. The more I study the

material the stronger my suspicion becomes that if we only observe

carefully enough we would find at least bits and pieces, if not the

panoply, of the estrangement syndrome, in these patients.

Drug abuse thus seems like an artificial depersonalization state

coupled with the next defense, externalization, which is so characteristic for “sociopaths.”

Are drug abusers perhaps nosologically a group uniting near psychotic estrangement with “sociopathy”?

Externalization-The Neglected Defense

I set externalization apart, because it does not only function as a

direct pharmacogenic affect defense (e.g., in stimulants, alcohol),

but it has an overriding importance in all drug users in the form of

seeking the solution to an inner problem on the outside, by action

and in concrete form, quite apart from the eventually successful or

failing function as affect defense.

This crucially important defense is the action of taking magical,

omnipotent control over the uncontrollable. Everything else

appears less specific compared with this peculiar and I think rather

novel form of defense, valid for all compulsive drug taking. The

anxiety is always there: “The various affects, like rage and depression, are going to overwhelm me.” This fear of the traumatic state

is powerfully warded off by the potent substance which is eaten,

injected, snorted, or smoked: “I have the power—via this magical

substance-to ‘master’ the rage, the pain, the boredom, etc.” It is a

specialized form of defense by acting-just as many analytic patients

feel they solve an inner problem by an outer action (or avoidance of

action), instead of by exploring, understanding and remembering.

Moreover, since the Archimedean standpoint we have to take in

psychoanalytic theorizing, after all, always addresses the inner stream

of feelings and thought, any such act as utilizing an external help to
5 6 PSYCHODYNAMICS OF DRUG DEPENDENCE

“cope” with the frightening feeling, is a form of externalizationjust like the picking of a fight by a guilt-laden patient or the carrying around of the powerful protecting lion by the boy who is afraid

of his own aggression.

Now all the rest falls into place too. Of course, one who magically

externalizes as a defense against being overpowered by frightening

affects uses the same defense in form of “concretization.” He says,

“It’s not I who feels, it’s society or the body which makes me suffer

from this unnamable tension”-what was already referred to as

hyposymbolization. One who thus externalizes by massive action

cannot form the guiding values and ideals-again abstract, symbolic

versions of early feelings toward persons. Instead the drug is a concrete, external, sought after vehicle of action. It stands in the place

of the group of the most potent symbols: values and ideals-and the

powerful drug effect replaces the power which values have for us,

thus the chemical mythology!

Archaic guilt and shame are all over the place anyhow in these

patients-the drug is both a magical protection, a talisman against

them-from the outside--and an implementation of this double

Nemesis-again from the outside. In other words: The drug tries to

ward off externalized (mostly not yet internalized) retribution and

humiliation, but simultaneously it functions itself as a punishment

and as a shaming, a shameful proof of weakness and failure. The

drug dependency is both a matter for boasting: the conquest of

shame, and a cause for shame: an obvious weakness and failure,

exposed for all to see, though anxiously hidden. The same interpretation holds for the archaic dependency and ties Kohut’s and Anna

Freud’s view which seemed to contradict each other, together: the

defect in inner structures lets the patient seek an external object of

magical power to depend on for this all pervasive control. Again it is

defense by externalization. Externalization thus proves the magical

key for understanding not only all the proposed predispositions,

but also so much of the external bluster. I have spoken sometimesin connection with some cases-of the “Quadrangle of Fire” as a

metaphor: All four “comers” are forms of externalization. It is the

yearning for total unbound freedom, yet fatally abused; it is the

need for security-lending structures, sought even as jail, but violently fought and rebelled against; it is the continuous search for

adoration, the external confirmation of self-infatuation, the parading of phallic self-glorification; and it is the self-destruction by external means, the continuous arrangement of life that the patient

has to flee like a hunted animal from police, mafia, vindictive whores

—or imaginary enemies.
WURMSER: MR. PECKSNIFF’S HORSE? 5 7

In contrast to paranoid states the crucial “mechanism ” of defense is not projection, it is externalization.

And of course “society” falls in with it: “they’‘-police, politicians, physicians, parents, public (these five external powers)—go

right along with the compulsive drug user’s demand for externalization: They punish, prosecute, shame, hunt, prohibit, set up

structure-inadvertently feeding this demand and becoming victims of it themselves.

In a sense the addict-like the paranoid-has been most successful

in making the world serve his inner defense. Just as paranoid leaders

influence world history by their terror-ridden projections, the

addicts influence social history by their incessant demand for externalization. The success of both lies in forcing their surroundings

near and far to play necessary roles in what is originally an internal

conflict. The world goes along in this game of externalization, just

as it does all too often with the projections of the totalitarian

terrorists (whose concrete ideologies are but icing on their cake).

These games of projection and externalization must have a potent

lure for the “masses” to fall in so willingly.

But to return to the defense of externalization. That is surely not

restricted to compulsive drug users.? Do we not find it in many

other patients (and nonpatients)? What then is specific for the form

externalization assumes in the addicted person (even in its extensions-the TV addict, the gambler, the food addict, the compulsive

smoker, the alcoholic)? It is the magical power invested in a thing;

the “thing” is endowed with control over the self, over the inner

life, over the feelings. The solution for any inner problem is sought

in this one magical thing or type of things. The parallel case of

endowing a person with such a magical power-very akin to the

addictions-is the symbiotic surrender (and domination) in very

regressed, often paranoid, but not necessarily psychotic patients.

On the other, healthier side are those neurotics who externalize all

over the place, but do not endow one thing (or type of things) with

any of this exclusive magical power.

Kazin put this dynamic fact excellently: . . . “the addict to alcohol, like the addict to anything else, believes that he can will a

change within himself by ingesting some material substance. Like

so many of the things we do to ourselves in this pill-happy culture,

drinking is a form of technology. . . . Drinking cuts the connections

that keep us anxious” (1976, p. 45).

It is also blatantly obvious that externalization is thus not solely

a defense mechanism, but also a wish fulfillment, above all the wish

for magical power, the subcategory of narcissism stressed earlier--

so again a compromise formation.
5 8 PSYCHODYNAMICS OF DRUG DEPENDENCE

A few theoretical addenda to the concept of externalization (cf.

Anna Freud [1965]) are in order here.

It is rather difficult to separate cleanly and clearly externalization

from projection. The way I conceive the difference is that the emphasis in externalization as a defense lies on action (including and

especially provocation), whereas in the case of projection as defense

the emphasis is put on emotionally distorted perception. Obviously

both often go hand in glove together.

We also can distinguish various modes of defensive externalization:

(a) by use of a magically powerful, mind altering, especially selfesteem increasing and affect-dampening substance or thing;

(b) by use of another impersonal agent as internal problem solver, like television, gambling, money, food;

(c) by use of an all-powerful, all-giving personal agent in symbiotic bonds or by fight against a totally evil enemy (here the

projections are particularly prominent);

(d) by lying, manipulating and evading all personal commitments;

(e) by transgressing in grandiose “acting out” the limits set by

nature and society (in what the Greeks called hubris, a

specific characteristic of the “tragic character”);

(f) by provoking retaliation in the form of shaming, of angry

punishment or of diffuse attack;

(g) by outright violence: to destroy a symbolic representative of

part of oneself, or, as in the just described mode, to bring

about punishment;

(h) by action as exciting risk, especially if forbidden and dangerous, in an attempt to get rid of an almost somatic uneasiness

and pressure, felt as primitive “discharge,” a breaking out of

being closed in, trapped, with undifferentiated but deeply

frightening tension within. We saw how very typically the

affect regression is experienced as a vague but broad, allpermeating tension, a drivenness and restlessness, a longing

for risk and excitement. This tension is perhaps the prototype for all other modes of externalization.

In all these examples an external conflict situation and action

ward off the internal conflict and the archaic overwhelming affects

stemming from it. It is a very primitive group of defense modes.

Also in all patients, this defense is combined with other defenses,

above all-as we saw already-with splitting, regression and of

course most massive denial, often with projection. All compulsive

drug users show all or most of the eight modes of externalization

described, concomitantly or alternatively.
WURMSER: MR. PECKSNIFF’S HORSE? 5 9

As a general characteristic of all defensive externalization, we discern its dehumanizing quality. With the defensive use of action, this

action itself is relevant, not the needs, qualities, properties of the

persons “used,” unless they happen to fit totally into this doing in

the service of the denial. It is mainly this dehumanizing use of

others which strikes us as so infuriating in all “sociopaths.”

Another aspect of it has been described again by Eissler (1950):

“ . . . their tendency to accept only the concrete part of external

reality as valid and valuable.” He adds that “The tendency toward

concreteness is mainly based on oral fixation and is also the result

of the comparative deficiency in the ability to sublimate, which is

significant of so many delinquents.” This last remark, however,

would lead us clearly into the question of predisposition and will be

touched upon in that section.

But it is important that this fourth stage in our sequence is

marked by the predominance of a magical, global form of externalization directed toward impersonal, concrete, dehumanized

objects and action for action’s sake.

An important aspect of externalization, in these patients at least,

is so obvious that it is almost omitted. The defense of externalization reestablishes the illusion of narcissistic power and control.

Most prominently in compulsive amphetamine users, but to an

only slightly lesser extent in all toxicomanics we find fulfilled a

feverish wish for autonomy, for being in control, an escape from

the panicky fear of not being in charge of one’s destiny, especially

the most ominous “ghosts,” the haunting representatives of one’s

inner life.

And since it is action, frenetic action, it always must perforce

use aggression in the service of this narcissism. Externalization is

obviously the exact opposite of inhibition: the blocking of the

feared and wished action. Thus again this stage can be comprehended as a compromise formation.

Summary of the Direct Antecedents

When we summarize this section and repeat its main points we

have to ask: “What is now the specific constellation, the final common pathway, immediately preceding acute beginning or resumption of compulsive drug use? What is essential and present every

time?” It is the following group of indispensable phenomena:

(a) We noticed the externally precipitated, internally strongly

experienced crisis in self-esteem, the severe narcissistic crisis, the

collapse of expectations and valuations of the self and of others,
6 0 PSYCHODYNAMICS OF DRUG DEPENDENCE

and the reactivation of archaic narcissistic conflicts in an acute

form. Their contents vary, from case to case, from time to time,

appear isolated or in combination; but the acute precipitation of a

conflict about self-esteem, valuation, meaning, in other words of an

acute narcissistic conflict remains.

(b) This is followed by affect regression, a totalization and radicalization of feelings. The narcissistic conflict is either accompanied

by overwhelming feelings of anger and rage, of shame and guilt, or

boredom and emptiness, of loneliness and depression, or by a vague

sense of wanting “excitement,” adventure, to feel alive, oneself,

awake, not estranged any more, a broad ill-defined tension, and

sense of emptiness. This totalization serves at least partly defensive

functions.

(c) The third component is the urgent, again acute, need to defend against these overflooding, overbearing affects-above all by

denial and dissociation; these two are the major affect defenses,

now pharmacogenically supported, because insufficient in their own

right. They affect not solely the emotional life and the underlying

instinctual drives, mobilized in the crisis (most prominently intense

sado-masochistic impulses, often of uncontrollable intensity), but

all of reality testing. It is an acute, pervasive, and characteristically

varying, labile, but very destructive ego split. The splitting up may

be of varied severity: in fetishism, a narrow one, or more extensive

disjunctions and partial fragmentations or an overall polarization

into all-good and all-bad. The combination of denial and splitting

very often leads to typical states of depersonalization and derealization, with and without drugs.

(d) The fourth, most specific, most intense component is the use

of externalization as defense: “I have to find an external solution

for the unbearable internal problem which I do not want to see,

cannot cope with, and yet am not able to avoid entirely either. I

have several ways of external action: If I cannot find the magical

substance, I choose one of the other avenues”-one of the other

seven modes described. They are initially exchangeable and typically combined. The crux is: action, “excitement,” risk—as a lightning rod for what is mobilized and denied.

(e) This defense by externalization carries intense sado-masochistic impulses with it; very often these aggressive intents are most

vehemently repressed and denied, feared to the extreme, and yet

palpably and indispensably present.

(f) There is not merely an ego split; there is a characteristic

sudden “inoperativeness,” a collapse of the superego, and an

appearance of much more primitive forms of superego functions, a

surprising, abrupt change from more mature, more integrated func-
WURMSER: MR. PECKSNIFF’S HORSE? 6 1

tioning of conscience, responsibility, ideals, to a much more primitive one, very often even a side-by-side existence of the two forms

of superego. This superego with a suddenly unmasked Janus head is

the split in the superego. This sixth constituent, ineluctable part of

the specific cause, the acute splitting of the superego, occurs under

the onslaught of the urge for externalization, for impetuous, impulsive, seemingly redeeming action.

(g) Finally, the end goal is getting “high” or at least finding

relief-the euphoria, the regressive pleasure, usually of a combined

narcissistic, oral, object-dependent nature, and, as part of the narcissistic fulfillment, a sense of being a cohesive, bounded self again.

Furthermore, claustrophilia wins out over claustrophobia.

This is the heptad of compulsive drug use, which we have called

the “vicious circle” and now described psychoanalytically as a

series of complex compromise formations, appearing in this order,

in this sequence, each dependent on its predecessor, a vicious circle

of mutual reinforcement and malignancy.

SOME COMMENTS ABOUT PREDISPOSITION

We have described a perspective on a horizontal plane, which encompassed mainly a microanalysis of the structural, dynamic, topographic and some economic and adaptational factors as they are

needed to understand the historically closest and logically most

specific antecedents directly leading up to the addictive syndrome.

We should add a vertical perspective-a look into the historical

depth of the personality, an attempt to see the aforementioned

factors in their genesis and unfolding.

Skepticism is particularly justified in our field. What Eissler

(1969) wrote in regard to treatment holds true no less for theory:

Strangely enough, psychoanalysis is not able to provide the tools with

which to combat the majority of forms in which drug addiction is

now making its appearance among the younger generation in the

United States. It seems that, just as psychoanalysis is, with few exceptions, not the method of choice in acute conditions, so it is not prepared to stem the tide of that form of psychopathology that is provoked by anomie. The dissolution of societal structures does not

travel solely the path of lessening the strength of institutions and

finally abolishing them entirely (at least for the time being), but also

the path of reducing structure in individuals. The structure of the

ensuing psychopathology seems to be quite different from the psychopathology whose treatment led to the evolvement of psychoanalysis

(p. 463) (my italics).

Thus we face the following obstacles to a genetic exploration:

(a) The methods of psychoanalytic inquiry have to be modified
6 2 PSYCHODYNAMICS OF DRUG DEPENDENCE

to such an extent in the treatment of these patients that the observations gained do not lend themselves easily to simple and minor

modifications of the theoretical abstractions gained by the classical

method.

(b) Very few patients stick to psychotherapy long enough to

allow us sufficient genetic reconstructions which would give us the

security of empirical probability.

(c) As Eissler noted there is such an intertwining of intrapsychic

with familial, societal, cultural pathology that we cannot investigate

and understand one without at least trying to do this for the others.

(d) The drug user himself is crippled by his very symptom in

some of the core processes of judgment and self-recognition.

Retrospective falsification is an ever-looming danger.

(e) The main tool of recognition in psychoanalysis, the transference neurosis, only most rarely becomes clear in treatment. The

therapist has to assume so much of a reality role, the patient is so

intolerant of deprivation, that very little indeed remains of the “asif” nature needed to explore in a systematic way the transference

aspects (Tarachow 1963)—no matter how hard a good, conscientious therapist and analyst tries to keep these parameters to a minimum. Very often the choice is between keeping the patient in treatment or even alive versus maintaining a therapeutic relationship

allowing a maximum of theoretic insight.

In favor of our efforts are, however, a few clear insights:

(a) The heptad (see page 47) gives us plentiful clues to tie very

many processes, seen in our patients as an ensemble, together with

similar processes in other patients where they may appear “in single

file.”

(b) There is no question that most or all of these patients suffered very massive traumatization all through their childhood,

mostly in the form of gross violence and crass seduction and indulgence. What neurotics show mainly as intrapsychic conflicts with

preponderance of fantasy, these patients experienced as massive

external conflicts of overwhelming dimensions from early childhood right through adolescence.

(c) Thus drug use is not simply an adolescent crisis gone awry (as

the parents regularly want us to believe).

All compulsive drug users whom I ever got to know show what

Kernberg so excellently described and studied as “borderline personality organization” (Kemberg 1967, 1970a and b, 1971, 1975).

Here I stress mainly the predominance of primitive mechanisms of

defense, i.e., of splitting, of primitive idealization, of early forms of

projection (“projective identifications”: “They have to attack and

control the object before [as they fear] they themselves are attacked
WURMSER: MR. PECKSNIFF’S HORSE? 6 3

and destroyed”), of primitive manifestations of denial (“ ‘mutual

denial’ of two emotionally independent areas of consciousness”),

and of omnipotence and devaluation. Kemberg also points to the

lack of superego integration and easy reprojection of superego functions, the protective shallowness of their emotional relationships,

their demandingness and exploitiveness, the chameleonlike quality

of their adaptability and “as-if” quality.

But any such excerpt does injustice to the depth and richness of

Kernberg’s concepts.

Suffice it to note here that the toxicomanic patient allows us a

detailed study of some of the traits shared by all “borderline”

patients-especially splitting, denial and idealization (let alone the

intolerance to anxiety and impulse, the blurring of ego boundaries),

-but also permits us to gain rather novel insights into the role of

manifold externalizations, the problems of affect tolerance and

affect regression in general (not just anxiety), the important role of

depersonalization, and especially the broad spectrum of various

forms of boundaries and limits.

(d) As Eissler and Kohut in particular emphasized: These archaic

personality organizations reflect a lack of inner structures which

early damage and family and societal pathology conspire to bring

about. A fourth aspect, usually omitted, may play a very important

role in this lack of inner structures: heredity. How important a role,

we have no way of knowing today, but this is a scientific problem

open to experimental solution.

(e) The seven factors enumerated in the heptad all point to very

archaic fixations-to problems in the first 2-3 years of life, to severe

damage suffered at the time when these inner structures need to be

built, when the child has to come to terms with frustrations to his

omnipotence, to oral gratification, when boundaries between self

and others are established, when he gradually learns to establish his

own regulations of self-esteem, and, most importantly, when his

affects become differentiated, put in symbols (including words, but

not restricted to them) and slowly become manageable (cf. Schur

1953, 1966, especially Krystal 1974). There is no question that the

severest damages in our patients lie in these early, largely preverbal

times, though perpetuated on and on, as massive narcissistic conflicts and primitive aggressions directed with little differentiation

against others and the self, as a general problem about boundaries

and limitations, as archaic forms of defenses, as structural deficiencies of manifold nature.

Although we need particularly in this area far more specificity than

our current theory provides us, I restrict myself to a cursory summary of the extensive findings presented in my full-length study.
6 4 PSYCHODYNAMICS OF DRUG DEPENDENCE

If I try to select the one trait in the personality of the compulsive

drug user which is most specific, it is the overall lability of inner

structures and of boundaries. Not only are the emotions inconsistent

and overwhelming, but so are the defenses, the self-other boundaries, generally the perceptual boundaries, and the limitations and

boundaries watched over by the superego. Clinical experience,

social and administrative observations and the test findings described especially by L. Kirkman (Wurmser 1977), all converge on

that one point: the inner “anomia,” lawlessness, the lack of consistency, structure, boundaries. As Kohut so rightly remarks: This is

the expression of a profound narcissistic defect. On the one side it

is the outcome of acute and chronic narcissistic conflicts; therefore,

the archaic, peculiarly narcissistic affects are overwhelming and

unrestrained. But on the other side there is also a profound deficit

in structures to cope in any consistent way, with the help of a reliable defense constellation, with such conflicts and ensuing affects.

Withal we encounter this peculiar shift of boundaries and limits of

all sorts, concretely and metaphorically.

The analysis regarding structure formation comes down to the

cycle shown in the accompanying figure. One may separate the five

elements into different defenses or defects; it is perhaps more accurate to view them as different parts of the same phenomenon which

appear as defenses and as defects. When we look at it as denial, we

emphasize the defensive aspect; when we stress splitting, we view

the double nature of disavowal or denial and acceptance or acknowledgment, especially from a cognitive point of view; and finally

when we focus on the boundaries, structures, and lack of effective

affect defense, we seek mainly the “defect” nature of the phenomenon.

Again,. as on the level of the immediate antecedents, we see the

entire constellation of the predisposition as necessary preconditions.

Among them I -consider this element of an inner “anomia,” this

peculiar lability in structures, as the most specific one.

The pathogenic conflicts probably reach, as in schizophrenics,

very far back: to the most archaic conflicts in perception and exPression and, with that, to the original forming of any boundaries

and self-nuclei. These conflicts are postulated to form a specific

part of what is too loosely and broadly known as the oral stage.

The massivity of other (though closely related and overlapping)

problems, especially of severe and archaic narcissistic conflicts in

the patient and the gravity of inconsistency, aggression and promotion of externalization and deception in the family, are invariably present. These other necessary parts of the precondition are:

hyposymbolization; labile, often externalized superego; defect in
WURMSER: MR. PECKSNIFF’S HORSE? 6 5

CYCLE OF STRUCTURE FORMATION

IN THE PERSONALITY OF THE COMPULSIVE DRUG USER

general lack of

reliable structures

and boundaries

externalization = transgression

and blurring of boundaries

basic detect in

allect defense

many forms of splitting

and fragmenting

global denial

as defense

ideal and value formation; prevalence of shame; massive aggression,

mainly of the rage and contempt type, more self-directed than

against others (cf. Wurmser 1974).

Even in the predisposition of the patient himself usually the

entire heptad described as the “final common pathway” can be

discerned throughout life and becomes usually very prominent in

adolescence.

If we compare this predisposition, the personality, the “set,”

with other nosological categories, the work with patients who are

not compulsive drug users (e.g., psychoanalytic patients) allows a

strong contradistinction: Above all, the intensity and archaic

nature of narcissistic conflicts are usually much more pronounced

in toxicomanics. The extent of boundary problems and the prevalence of the very archaic defenses of denial, splitting and externalization are most striking. Neurotics use, instead, much more repression, introjection, or the obsessional defenses. Projection appears

in both to a moderate extent. The superego pathology is far deeper

in addicts than in all types of neurosis. Finally, a strong case can be
6 6 PSYCHODYNAMICS OF DRUG DEPENDENCE

made that the peculiar form of aggression which is evident in

shame, namely contempt, disdain, scorn, plus undifferentiated

rage, but less anger and hatred, are the ones which are particularly

prominently used in the service of externalization in these patients,

and this even more in a self-directed, masochistic version, than

against the outer world.

In contrast to the various psychoses the extent of ego split and

superego split and, more generally, of fragmentation of cognition

and perception is less strong in addicts. Projection, dehumanization,

depersonalization are much stronger in psychotics during the acute

phase than in addicts. Recompensated psychotics have much in

common with recompensated addicts: If anything, the propensity

to the characteristic splits, fragmentation, denial and externalization, even projection, the extent and massivity of narcissistic and

sado-masochistic problems may even be more manifest and conspicuous in the addictive than the latently psychotic personality.

The theoretical conclusions presented here could serve us as a

starting point to go in three directions-first, to systematic research

of the hypotheses presented here, second, to a more thorough

metapsychological exploration of these clinical observations, and

third, to applications for prevention and treatment which would go

beyond the present mad rush into action before thinking.

Research would have to proceed from this nodal point of the

etiological equation in several directions. Of course, one road would

lead simply toward confirmation (or refutation) and deepening of

these findings. Another even less paved road would be a genetic

exploration tying the described defects and conflicts together with

developmental disturbances and family pathology. On another path,

one would have to study the constitutional factors involved; at this

point, we have no way of knowing how much of the underlying

problems are of hereditary nature. Yet study beyond speculation is

particularly tantalizing in this area. Still another route goes in an

altogether different direction: The defects in ideal formation may

open a deeper understanding for value psychological and value philosophical questions; thus such a study would assist us in a more

thorough theoretical superego analysis than has been known hitherto.

TREATMENT

A few fragmentary thoughts about treatment need to be added,

first, regarding psychotherapy and then regarding large-scale treatment policy.
WURMSER: MR. PECKSNIFF’S HORSE? 6 7

Psychotherapy

One thing is clear above all: One cannot do “business as usual”

with this type of patient. They resemble in many regards psychotic

patients. Despite the usually dismal prognosis, I have seen a number

of very severe chronic drug abusers successfully in long-term therapy. I think in particular of several patients who had been dependent for 10-20 years on very high doses of amphetamines (100 mg

and more, or similar stimulants) or of narcotics (with dosages of

100-800 mg of methadone daily), whom I saw for one or several

years. Looking back over these experiences, I single out one precondition of treatment which has facilitated successful treatment in

several instances: the readiness on both sides for intensive, analytically oriented work and to stick it out no matter what. By “intensive” I mean often-in times of crises three to seven sessions a week,

and sometimes much longer than 1 hour, plus telephone availability

in times of lesser urgency. I have had cases who decompensated

repeatedly and required brief hospitalizations (e.g., for suicidality

in the case of amphetamine abstinence-often many months after

withdrawal), but were able to work out their problems sufficiently

in such very intensive psychotherapy that they were not only

capable of assuming highly responsible positions, but eventually

also to enter psychoanalysis proper. Given the severely regressive

nature of the entire personality organization, it gradually became

clear to me that the treatment situation has to encompass the

following built-in transference elements:

(a) It has to have strongly nurturing, supportive elements without, however, feeding into the often overwhelming fears in the

toxicomanic patient of engulfment. The therapist has to be far

more active, warm, interested, personally involved, yet again without becoming intrusive, as very often the mother was.

(b) Also in all instances the exact counterpart has to be observed

as well: to maintain distance, to be very patient, not pressuring,

almost detached, without, however, supporting the profound sense

of abandonment and despair so deep in these patients. One has to

create a clear boundary of separateness, an atmosphere of nonsymbiosis and respect for individuality while still allowing symbiotic conflicts to be expressed and to become interpretable. The

patient must not feel exploited and treated as a nonhuman object,

no matter how much he may try to do that to the therapist.

Clinical experience appears to indicate that there may be indeed

two basic types of compulsive drug users, one far more afraid of

engulfment (a preponderantly claustrophobic type), the other fear-
6 8 PSYCHODYNAMICS OF DRUG DEPENDENCE

ing much more isolation and loneliness (in whom claustrophilic

needs prevail).

In the first type the distance needs to be preserved far more and

far longer for trust to arise, whereas in the second type far more

direct support is needed, making up for a traumatic sense of object

loss.

In most cases, though a delicate balance needs to be found somewhere in the middle, a constant empathetic weighing is required of

whether more nurturing or more distance is needed at the given

moment.

(c) Limit setting, external structure is absolutely crucial. Time

and again the patient needs to be faced with the alternative of curtailing some particularly noxious form of acting out or of forfeiting

any true benefit from therapy and even the gains already attained.

Each time of such an intervention is a crisis for the therapy. The

patient may concur and work on the intense anger this limit setting

evokes, with additional gain in self-control and with that in the

ability to observe himself and in the working alliance. Or he may

bolt, revolt, vanish, seeing the therapist’s guardianship of boundaries

and limits as yet a new form of entrapment, of intrusion, of enclosure. Therefore such interventions have to be used very sparingly

and without any moralistic implication: Transgression of ethical or

of any other boundaries has to be treated strictly as a symptom

with severe self-destructive potential, the compulsiveness of which

is the sole concern, not its antisocial (or socially positive) valence.

(d) This leads naturally to problems of counter-transference. Outrageous disregard of limits is often enacted precisely to provoke

rage, punishment and scorn from the therapist and thus to reconfirm the masochistic triumph. “No one can ever be trusted. I am

suffering again betrayal and degradation, and thus I prove the basic

unworth of human relationships; I can rely only on my actions and

on nonhuman substances.”

Or in turn the therapist becomes a masochistic partner, forced by

the ostentatious suffering of the patient into endless giving and

giving-in, or into going along with and thus once again indulging the

severest, most pernicious regressions.

Again the therapist has to find a golden mean: actively to set

limits, but without anger, sadism, shaming, and vindictiveness, and

yet to be very flexible, patient, always oriented not toward ethical

values in a narrow sense, but toward the central psychoanalytic

value outlined.

(e) This demand for giving and indulgence may in some cases be

overwhelming, especially in massively spoiled or severely neglected

patients. The transference-countertransference bind may turn into a
WURMSER: MR. PECKSNIFF’S HORSE? 6 9

sado-masochistic nightmare, a severe negative therapeutic reaction

and hence into defeat: rage, pain, hopelessness alternate with insatiable demands. Here the dilution of the dyadic therapy relationship

may save both treatment and life. In a number of cases the splitting

up of the therapeutic approaches, e.g., into a combination of individual, family and group therapy, carried out by different therapists, proved far superior to individual psychotherapy alone. This is

again an approach directly contravening the one-track mentality

already criticized (cf. also E. Khantzian).

(f) Whereas the transference-countertransference constellation is

a kind of perversion of intimacy, the next is a type of distancing

which can reach extreme proportions. In many patients it may take

a real therapeutic moratorium of months, even years, of passive

drifting, boredom, interrupted treatment, apparent endless stagnation, of a deep gloom of despair and hopelessness in the patient, at

times effectively transmitted to the therapist, until a solid basis of

trust has grown to start therapy in earnest.

This moratorium of passivity might be necessary not just because

of the deep fear of intimacy, of the claustrum and thus the devouring, englutting mother, but also (and connected with it) because of

dread of murderous aggression unleashed in submission to the

power of the stronger “other.”

In order to tolerate such a lengthy moratorium the therapist has

not only to be patient and rather at peace with his own narcissistic

needs, but I believe it likely that he needs two additional traits:

First, he has to see in the patient strongly redeeming features,

e.g., in the case described (p. 43ff.), there was an intense feeling

in me, through the years of despair: “What a waste of a capable,

likeable, highly gifted, basically honest person!” In this feeling of

respect and esteem for him, there was of course a lot of hope,

which kept outweighing nearly always the massive despair. Second,

the therapist has, as Freud stressed, to subordinate his therapeutic

zeal to scientific curiosity: to understand and to help to understand

must take precedence over the wish to heal, to mold according to

one’s own value priorities. To wait may mean to build up trust and

to show caring; but then to step in and to set the right limits at the

right moment (the “kairo’s”) may be critically important.

(g) The working alliance was defined by R. Greenson (1967) as

“the relatively nonneurotic, rational rapport which the patient has

with his analyst” (p. 192). I believe this concept to be equally

applicable to the analytically oriented psychotherapy commonly

chosen with these patients. In most instances these patients are too

sick, too self-destructive, too demanding to leave much room for

such rational cooperation. At first their attitude merely consists of
7 0 PSYCHODYNAMICS OF DRUG DEPENDENCE

a gut reaction: “I have suffered enough; I want to start anew. The

price I paid in the past I am not willing to pay in the future.” Thus,

it is not so much the value of rationality which attracts them, but

the fear of further pain and suffering which pushes them from

behind. But as the time passes (again often years) an identification

with the value of inner freedom, of self-mastery, of non-condemning

exploration and knowledge, as represented by the therapist, may

replace the more archaic ego ideals, and gradually lend more and

more force to rationality and thus to the working alliance. Hence,

shame and guilt may become associated with such a standard of

reason instead of the grandiose self-image which had ruled supreme.

Large-Scale Treatment Policy

Heavy (compulsive) drug use is coextensive with moderate to

severe psychopathology underlying the drug use, not caused by it.

The crisis in the treatment of these patients who are either rejected

or inadequately treated by the currently existing programs is also

coextensive with the crisis in the treatment of emotionally disturbed or outright mentally ill patients in general. Innovative facilities should be created employing the gamut of already known

psychiatric techniques to this class of patients; it appears imperative

to develop and implement innovative psychotherapeutic techniques

specifically for this type of pathology-combining in-depth dynamic

(psychoanalytic) understanding and leadership, structure building

and limit setting, family treatment, vocational retraining (or new

training), opening up of creative or recreational avenues of gratification, and the flexible use of psychopharmacological agents. In

other words: Instead of one-track modalities we need combinations

of four to seven methods for each individual patient in a methodical,

specific way.

Such a plan calls for the avoidance of many of the current

faddish “short-cuts” and fashionable new “simplistic” techniques,

because of their destructive potential with these severely ill patients.

It requests a deeper involvement in the positions of leadership by

psychiatrists and psychoanalysts in dealing with the majority of the

problems of compulsive drug use. The current debunking of a

thorough training in psychiatry and especially in intensive individual psychotherapy, and with that the nearly total lack of understanding for the psychodynamics of these patients and their families

has been devastating for psychiatry in general; but it has left the

field of treatment of these patients almost entirely to paraprofessionals and to specialists from other fields who are naive as to the
WURMSER: MR. PECKSNIFF’S HORSE? 7 1

gravity and nature of the psychopathology in the majority of these

cases and as to measures for devising rational treatment strategies

for each individual case.

Most specifically, it calls for a deeper involvement of psychoanalysis in such a leadership role, not as a treatment method, but as

the only accredited institution which has set itself the goals of a

deeper systematic understanding of the human mind and of a

methodical, thorough, well-structured and supervised training of its

practitioners. Despite its current external and even internal crisis,

its factual contribution to the huge problem at hand could perhaps

be the most innovative suggestion this report can make-as old

fashioned as it may sound to many readers.

Reluctantly, I have to break off. What I have presented is, naturally, condensed, fragmentary, but I believe it may give some hints

whither the new developments evolving from intensive therapy have

led us so far and may point onward.

To finish, suffice it to say that we cannot remain, in this field

which often appears to me beset by ponderous rhetoric and fatuous

motion, like Mr. Pecksniff’s horse (in Dickens’ Martin Chuzzlewit),

“

, . . full of promise, but of no performance. He was always, in a

manner, going to go, and never going.”

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Buchges, 1958.

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On isolation. Psychoanol Study Child, 14:29-60, 1959.

Irreverent remarks about the present and the future of psychoanalysis.

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Death drive, ambivalence, and narcissism. Psychoanal Study Child,

The fail of man. Idem. 30:589-646, 1975.

Freud, A. Normality and pathology in childhood. In: The Writings of A. Freud,

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Civilization and Its Discontents (1930). SE. XXI, London: Hogarth

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Greenson, R.R. The Technique and Practice of Psychoanalysis. New York: Int.

Univ. Press, 1967.

Hartmann, H. Notes on the theory of sublimation (1955). Essays on Ego Psychology. New York: Int. Univ. Press, 1964, pp. 215-240.

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Notes on the theory of aggression. id. 3/4:9-36, 1949.
7 2 PSYCHODYNAMICS OF DRUG DEPENDENCE

Kazin, A. “The Giant Killer”: Drink and the American Writer. Commentary,

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Kernberg, O.F. Borderline Personality Organization, J Am Psychoanal Assoc

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Factors in the Psychoanalytic Treatment of Narcissistic Personalities.

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A Psychoanalytic Classification of Character Pathology. J Am Psychoanal Assoc, 18(4):800-822, 1970.

Prognostic Considerations Regarding Borderline Personality Crganization J Am Psychoanal Assoc. 19(4):595-635, 1971.

Borderline Conditions and Pathological Narcissism. New York: Jason

Aronson, 1975.

Khantzian, E.J., Mack, J.E., and Schatzberg, A.F. Heroin use as an attempt to

cope: Clin. obser., Am J Psychiatry, 131:160-164, 1974.

Krystal, U. The genetic development of affects and affect regression. Ann Psychoanal, 2:93-126, 1974.

Krystal, H., and Raskin, H.A. Drug Dependence. Aspects of Ego Functions.

Wayne State Univ. Press, 1970.

Kubie, L.S. The fundamental nature of the distinction between normality and

neurosis. Psychoanal Q, 23: 167-204, 1954.

Lichtenberg, J.D., and Slap, J.W. Notes on the concept of splitting and the

defense mechanism of the splitting of representations. J Am Psychoanal

Assoc. 21:772-787, 1973.

Moore, B.E., and Fine, B.D. Glossary of Psychoanalytic Terms and Concepts.

New York: Amer. Psychoanal. Assoc., 1968.

Rado, S. The psychoanalysis of pharmacothymia (drug addiction). Psychoanal

Q, 2:1-23, 1933.

Rochlin, G. Man’s Aggression. The Defense of the Self. Boston: Gambil, 1973.

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CHAPTER 5

Substance Abuse: An Understanding

From Psychoanalytic Developmental

and Learning Perspectives

Stanley I. Greenspan, M.D.

The problem of substance abuse in any one individual must be

understood in terms of the multiple lines of his development. It is.

not enough to simply view the substance abuse as a means of acting

out an unconscious conflict with authority, or dealing with an

underlying deep depression, or as part of a chronic antisocial character pattern. For any given individual, all, or none of these, might

be contributors. Instead, in studying the problem of substance

abuse, a model is needed within which the personality can be

viewed from multiple perspectives at once. This is consistent with

the psychoanalytic principle of multiple determination. According

to this thesis, all behavior is a product of multiple determinants,

e.g., unconscious and conscious, as well as genetic, adaptational,

structural, and dynamic. Thus, for a given individual, using an

addictive drug might incorporate at the same time, the satisfaction

of certain primitive impulses and needs, a structural defect in one of

the ego’s substructures dealing with impulse or affect regulation,

and an adaptation to an extraordinarily stressful environment.

Just two perspectives that the psychoanalytic model brings to

understanding problems of substance abuse will be considered to

illustrate the principle of multiple determination and the problem

of drug addiction. The first is a developmental perspective; the

second, an extension of the adaptational point of view, is a psychoanalytic learning model.

What follows will highlight some aspects of the developmental

view of substance abuse so as to illustrate how different levels of

development may contribute to a complex behavioral pattern.

Though couched in terms of male development, the analysis is gen73
7 4 PSYCHODYNAMICS OF DRUG DEPENDENCE

eral enough and should be understood as applying as well to female

development.

First, consider that the infant attempts to reach a state of homeostatic peacefulness. He brings with him into the world a number of

basic rhythms which help him achieve this. His environment helps

to protect him from overstimulation and provides the physical and

emotional nurturance necessary for him to obtain these peaceful

homeostatic states. During this early period, in the context of a responsive and supportive maternal object, the infant begins his important task of attachment. He begins the first step in developing

his uniquely human relationships. At the same time, his primitive

impulses are beginning to organize around orality as a means of

engaging the environment and achieving pleasure. His ego structure

is beginning to attain some initial capacities for regulating his internal experience and finding effective ways of relating to his primary

maternal figure and the inanimate aspects of his environment.

However, should either innate constitutional characteristics or a

chronically severe traumatic environment hamper him in attaining

these initial steps in his development, the infant may suffer severe

deviations. For example, failure to attain the capacity to achieve

regulation or homeostatic balance in the context of an attachment

to a maternal object could be one determinant, among others, of

later substance abuse. It is not uncommon to hear a substance

abuser talk about the need to obtain the most basic and primitive

kind of homeostatic experience. Often, this kind of basic stability

in his internal world seems to be what is lacking. The substance, be

it heroin or some other narcotic or stimulant, works at a physiologic

and psychological representational level to facilitate the attainment

of this basic homeostatic experience. Here, therefore, we can see a

derivative of substance abuse behavior emanating from a very early

period in an infant’s life, even before the basic attachment to the

maternal object.

Developmental deviations will occur if an infant does not achieve

the basic capacity for attaching to a human object for a variety of

reasons, e.g., unusual constitutional sensitivities on the infant’s part;

or a lack of availability of a pleasurable maternal object; or characteristics unique to the interaction of the infant with his primary

maternal object. Substance abuse could emanate from the lack of

this basic ability of attaching to the human object. In essence, substance abuse can become a substitute for this attachment. For some

individuals basic attachments of this kind are possible only under

the influence of drugs.

If an infant does obtain the developmental accomplishments

needed to establish an emotional investment and attachment to a
GREENSPAN: DEVELOPMENTAL PERSPECTIVES 7 5

primary maternal object, he next discovers whether it is possible to

get his needs met in the context of this human relationship. It is in

this context that the infant also learns, through feedback from the

maternal object, to experience aspects of his own internal world.

Even basic states such as hunger become, in part, recognized by the

infant through the responses his hunger elicits from the environment. Initially, it is feedback from the environment that allows the

infant to understand the “means-ends relationships” within his own

body. If certain internal feeling states, expressed by the infant, lead

to certain predictable results in the environment, there is a consolidation of these early cognitive and affective schemes. It is not difficult to see how substance abuse at a later time could derive from a

disturbance in the normal development of these early schemes.

Hilde Bruch (1973), in her work with anorexia and overeating, has

hypothesized a basic defect in the ability to experience internal

feeling states such as hunger. Thus, anorexic people eat or do not

eat because of external forces that are removed from the internal

need state. In clinical interviews, many substance abusers speak not

just of a sense of depression or deep internal pain, but of an anhedonic experience of feeling nothing inside; only a drug experience

gives them an internal feeling state. This could be related to early

experiences where the preliminary psychological structures necessary for experiencing organized feeling states are not constructed,

due to an impairment in the early infant-mother interaction

patterns.

As the infant moves toward the end of his first year, he should be

beginning to consolidate a separate image of his “self” from the

image of the primary objects around him. One could hypothesize

how an inability to fully consolidate the self-other boundary could

lead to the overwhelming anxieties often associated with later substance abuse. In this instance, the ingestion of addictive substances

serves to consolidate for the individual an organized nonaversive

sense of self, whether artificially induced by a drug “high” or

“low.”

If development thus far has been successful and an adequate

attachment has formed between the infant and the primary maternal object, the task of separation and individuation then becomes

crucial. While the infant, early in his second year of life, is demonstrating his increased motor coordination by crawling, walking, and

running from room to room, we often note that he returns to his

mother or other primary objects for “refueling.” In this phase, he

shows curiosity and takes delight in his environment. According to

Mahler (1971), he is acting under the all-encompassing umbrella of

parental omnipotence. During this stage, the infant can achieve an
7 6 PSYCHODYNAMICS OF DRUG DEPENDENCE

important sense of mastery. If, for example, this is interfered with

because of a mother who needs to hold the infant too close, who is

frightened of permitting the separation process to occur, the consolidation of the sense of mastery and the delineation of the infant’s picture of himself as a separate being from his primary objects may suffer severe impairment. Because all this is occurring

during a period of rapid growth in motor coordination, the infant

has greater capacities to experience and channel aggressive feelings.

At the same time, toward the middle and latter part of the second

year, the infant’s instinctual organization is beginning to organize

around the mental representations concerned with anality. It is

quite possible during this period, therefore, for interferences in

optimal development to result in personality organizations that are

either extremely passive, extremely negativistic, hostile and belligerent, or extraordinarily impulsive (almost as though to burst out of

mother’s grasp). Underlying all these personality organizations may

be the primary impairment of an internal sense of mastery and delineation of self from the primary other. The use of drugs in an

effort to obtain this primary, never acquired state of mastery and

the clear demarcation of self that accompanies it, is also seen in

clinical interviews with many substance abusers. The conflict during this developmental stage when the infant is at once merged with

the parental omnipotence, but at the same time needs the freedom

to explore his world, is also seen in those substance abusers for

whom the underlying dynamic is related to unresolved issues of

merging and separation. The substance becomes a way of obtaining

a sense of oceanic merging with the omnipotent object and, at the

same time, is safe enough, since it is a drug and not the omnipotent

object. The user is not afraid of being literally “swallowed up.”

If, in the context of a supportive family environment, the infant

succeeeds in achieving the sense of mastery associated with the 12-

to-18 month period of life, his maturational progress in the cognitive sphere permits him further to perceive his own “self” as distinct from others and to realize a sense of his own size in relation

to his parental figures. For the first time the infant sees that indeed

he is not a part of his mother, but rather, that he is totally separate

and quite small. This can be very frightening. Margaret Mahler

(1968) points out that it is during this “rapprochement” phase of

development that the infant often returns to the primary maternal

objects for further dependency support, going through another

gradual separation process and emerging optimally into what Mahler

refers to as the “libidinal object constancy” stage. According to

Piaget (1952), with his growing capacity for “figurative thinking,”

that is for mental representation, the toddler can now have a
GREENSPAN: DEVELOPMENTAL PERSPECTIVES 7 7

picture of himself and his environment that is relatively more realistic than was possible for him at an earlier phase of his life. This

capacity for mental representation places a new burden on him.

Piaget (1952) and Mahler (1968) both agree that the infant and

young child now repeat many of the steps that occurred earlier in

development as they re-work issues at a higher level of mental

representation than were first achieved at the level of acting on the

environment. If the mother and/or others are not available to give

the extra needed supports during this “rapprochement” phase, the

child may experience tremendous anxiety, resulting in possible

personality distortions.

Difficulties stemming from this crucial phase of development

might, for example, center around a precocious sense of independence superimposed on a precarious, somewhat fragmented selfrepresentation. Severe impairments in self-esteem and depressive

constellations may develop. Because of the increased capacity for

organized aggressive behavior and ego differentiation which accompanies the capacity for figurative thinking, a variety of defensive

organizations may become manifest, such as impulsive acting out,

depression, psychosomatic difficulties, and severe antisocial behavior patterns.

All of these can accompany underlying masochistic personality

organizations consistent with the anal phase of instinctual organization. It is not surprising that we see a strong masochistic component

in many severe characterologically resistant substance abusers,

where the abuser is at one and the same time hurting himself and an

internalized loved/hated object. Such behavior may very well emanate, in part, from this developmental period where the dependedupon object may have been perceived in a strikingly ambivalent

way. At the very time it was the only available hope for dependency

satisfaction, it was also the source of tremendous torture and suffering, since it did not fulfill these expectations of satisfaction. Thus,

we can see how the substance that is being abused can serve multiple functions simultaneously. It can represent the ambivalently

regarded object; it can provide the state of satisfaction sought after;

and it can provide the outlet for the sadistic and masochistic components of unresolved rage.

As the young child moves toward the third year of life, it becomes possible for him to obtain true libidinal object constancy;

that is, it becomes possible for him to retain a constant internal

image of himself and important others. He can construct a constant,

delineated boundary between those organized representations of

himself and others which provides the foundation for differentiated

ego structure and the ego functions, such as reality testing, impulse
7 8 PSYCHODYNAMICS OF DRUG DEPENDENCE

regulation, and synthesis of different internal and external experiences. This is occurring in the context of an instinctual organization

shifting from anality to phallic concerns. In order for object constancy to be consolidated, however, the child must first be capable

of experiencing mourning. To become capable of greater independent functioning, he must relinquish his dependent attachment to

the real primary maternal object and go through a mourning period.

If he is successful, he can then move into the phallic Oedipal stage

proper, with a solid, differentiated ego structure to help him contend, with the vicissitudes of drive and object relationships consistent with this new phase of development. Many youngsters, however,

because of unresolved earlier issues, or because of familial circumstances, are not able to experience mourning and consolidate the

internal representation of themselves and important others, and

thus do not completely attain the stage of libidinal object constancy. Instead of letting go through experiencing sadness and

mourning, they cling to the dyadic partner and defend against

anticipated sadness and depression.

Substance abuse problems derived from this developmental phase

often manifest themselves in the context of a fairly well organized

character structure, although one which is incapable of feeling sadness or depression. Often, acting out and other antisocial defenses

are then used as a way of attaining a kind of pseudophallic exhibitionism in the service of defending against underlying feelings of

sadness and depression which have never been consciously experienced. The substance abuse, in this sense, is a defense against separation anxiety and its accompanying depression. Patients with difficulties stemming from this developmental stage, in long-term therapy may eventually talk about the fragility and tenuousness of their

sense of self and/or others. Their concerns are heightened when

they experience strong feelings such as anger, or during periods of

separation. The patterns of substance abuse associated with this

developmental period may be more intermittent and partially

exacerbated by certain feeling states or experiences such as separation or loss.

If development has successfully emerged from this period of

libidinal object constancy, the next major developmental task is to

move into the triangular relationship patterns and the phallic

Oedipal period proper. During this period, ages 3% to about 6, the

youngster becomes capable of organizing his personality in the context of a differentiated ego structure. All earlier conflicts and

developmental interferences become organized in the “infantile

neurosis.” The infantile neurosis, in this sense, is an organizing

structure which brings together all that has preceded it in the most
GREENSPAN: DEVELOPMENTAL PERSPECTIVES 7 9

economic fashion possible. The young child is now capable, for the

first time, not only of internalized conflict, but of organized conflictual structures which, on the one hand, may be the precursors to

later neuroses, but on the other hand, are an important developmental accomplishment. The personality achieves a certain cohesion,

organization and structure which permits it to tolerate a wide range

of internal and external experiences. A person who has achieved

this stage has a relatively greater adaptive capacity than one who is

fixated at an earlier developmental stage.

Individuals who have achieved this developmental level do not

often manifest severe substance abuse problems. They tend rather

to manifest organized neurotic and mild characterologic problems.

However, if the neurotic structure is sufficiently incapacitating,

substance abuse can be one way of diminishing anxiety. The substance abuse pattern may contain elements of unresolved Oedipal

conflicts in both the positive and negative Oedipal organizations,

as well as regressive preoedipal constellations either in isolation or

as part of a consolidated neurotic structure.

Thus far, the relationship of different levels of the development

of substance abuse patterns has been considered separately. In real

life, of course, one may see a clustering of problems from many of

these levels. An individual may deal adequately, if not optimally,

with one stage of development and bring residual problems from

that stage to a subsequent stage where there are additional problems. Thus, behavioral patterns become organized around multiple

determinants from multiple developmental levels.

In addition, however, to have a complete understanding of any

behavioral pattern, one must also consider dynamic, structural, and

adaptive components of that pattern. While these additional determinants will not be dealt with at this time, they are also important.

PSYCHOANALYTIC LEARNING PERSPECTIVE

There is an additional perspective that combines elements of the

psychoanalytic model with the operant learning model. In considering the problems of substance abuse, it is particularly important to

enhance the existing perspectives already considered by psychoanalytic psychology with the psychoanalytic learning perspective.

The theoretical base for a psychoanalytic learning perspective was

developed in an earlier work (Greenspan 1975). The model derived

from that work will be used for this discussion. The learning perspective forcuses on how certain features of environmental experi-
8 0 PSYCHODYNAMICS OF DRUG DEPENDENCE

ence impact on the ego to influence behavior. The psychoanalytic

learning model is unique in that it defines external experience in

terms of classes of discriminative stimuli and reinforcers which are

derived from stage-specific organizations of the ego and drives. For

example, a substance abuser who achieves a basic and primitive

homeostatic experience by using his addictive drug may be obtaining tremendous and potent reinforcement from the substance

abuse. Reinforcers found in the environment may be undifferentiated and, therefore, of multiple types and found in multiple places.

They may be defined as homeostatic-producing reinforcers. Not

only drugs, but, for example, certain states of consciousness, or

certain interaction patterns with important persons, may produce

the homeostatic experience. Once a class of reinforcers functions

as “homeostatic-producing reinforcers,” the way in which this class

of reinforcers operates instrumentally on the organized behavior

patterns derived from the properties of drive and ego organization

may play an important role in shaping substance abuse behavior

and in making it more or less resistant to change. For example, it is

well known that behavior under the influence of random schedules

of reinforcement is relatively more resistant to change than behavior under the influence of continuous schedules of reinforcement. A substance abuser who uses drugs to achieve a “pleasurable

high” only occasionally may be more difficult to wean from the

drug than an abuser who uses drugs to achieve a “high” continually.

While it is not possible to go into detail here about learning theory,

it is important to note that learning theory extends our understanding of how the environment influences, shapes and modifies behavior in ways that are not at all obvious to “commonsense.” It

becomes especially important to have a learning perspective when

dealing with an individual whose development has been arrested

before he was able to fully internalize conflict and form integrated

internalized structures. A person with an undifferentiated drive

organization and a relatively undifferentiated ego structure experiences his environment with multiple peremptory needs and wishes,

along with basic feeling states of incompleteness. Because of a lack

of internalized control and the number of potent internal forces

working from within, he tends to be vulnerable to environmental

influences in rather dramatic ways and is sensitive to many potentially reinforcing events in his external environment. His behavior is

more easily molded by external forces than the behavior of an

individual who has achieved a higher level of personality integration. The reinforcing properties of the environment must therefore

be considered as another determinant of behavior alongside the

multiple determinants that have already been considered.
GREENSPAN: DEVELOPMENTAL PERSPECTIVES 8 1

In addition to the developmental determinants already described,

and the structural, dynamic, and adaptive determinants only

alluded to, we must’ also consider learning determinants. We must

understand the environmental determinants that have rather specific effects, depending on the structure and character of personality

organization. The psychoanalytic learning model referred to earlier

can help us understand the effects of environmental stimuli on the

organization and maintenance of maladaptive patterns of behavior.

The learning perspective can be especially important as we design

and set up treatment programs. We know from past experience that

helping the substance abuser to reach a greater understanding of

internal experience, including broadening his capacity for experiencing a wide range of internal ideas and feeling states may not be

sufficient treatment. Often, the abuser acts out, or leaves treatment

before he can be helped to reach a state of internalized regulation

and self-esteem maintenance. To help a substance abuser stay in the

treatment relationship so that psychological growth may occur requires an intricate understanding of how the external environment

is interacting with his internal personality organization.

AN INTEGRATED MODEL TO UNDERSTAND

SUBSTANCE ABUSE PATTERNS

One approach to understanding patterns of substance abuse is in

the context of a broad understanding of personality organization

and its relationship to the organization of the environment. Along

these lines, we might develop a grid designed to consider a number

of aspects of personality functioning and related environmental

factors in a developmental context. This grid might depict, starting

at the top left comer, the level of drive organization; next, the

organization of affects; next, the organization of internalized object relationships; next, the level and style of ego differentiation;

next, the relationship patterns the person has achieved in the external world; and next, the organization of the person’s external

reality including the availability, patterns, and schedules of potent

discriminative events and reinforcers. If these different categories

were placed horizontally at the top of the grid, and the developmental phases from infancy to adulthood placed vertically at the

left-hand side of the grid, we could then trace where the individual

was at in a developmental context. Such a pictorial presentation

might help us to understand better the pattern of substance abuse

in the context of multiple aspects of personality functioning. Type

of drug, pattern of use, accompanying psychopathology as well as

strengths might be related to certain personality characteristics.
8 2 PSYCHODYNAMICS OF DRUG DEPENDENCE

To be able to arrive at a comprehensive personality assessment

and to understand the complexities of types and patterns of substance abuse requires, at the practical level, some personality assessment scales. These scales would permit people engaged in working

with substance abusers to begin thinking systematically about this

very difficult group of patients. To this end, reference should be

made to some existing ego assessment scales, including those by

Bellak (1964), and Greenspan and Cullander (1973).

The appendix of this paper contains a few items from the Greenspan and Cullander profile which may be used as a beginning in an

attempt to define more systematically some of the personality

characteristics which contribute to the type and patterns of substance abuse. It should be noted that this is only a beginning and

conceptualizes only a few lines of personality organization. Items

chosen from the profile were those that are relatively easy to score

and are tied most closely to observable behavior. The items in

the appendix are by no means a complete inventory, but represent

a kind of screening of certain ego functions at a general level. It is

hoped that this will begin the process of systematic assessment of

all substance abusers in order to understand better their similarities

and differences.

APPENDIX1

1. Ego intactness (vs. ego defects)

Included in this category is the general basic integrity of the ego in

terms of an evaluation of the ego apparatuses and functions.

(a) Ego Apparatus-This category includes the basic organic

integrity of the ego: for example, the perceptual apparatuses

(visual, auditory), the motor apparatuses, apparatuses that coordinate these (perceptual-motor), and other similar apparatuses, such

as memory, that have to do with the integrity of the mental apparatus.

(b) Basic ego functions-This category should include only the

basic overall functions of the ego (reality testing, predominance of

secondary-process thinking, presence of ego boundaries). Special

attention should be paid to the more subtle aspects of these functions that will give the interviewer clues about well-hidden borderline organizations; for example, preponderance of magical thinking,

1Reprinted with the permission of International Universities Press, Inc.,

from the Journal of the American Psychoanalytic Association, Vol. 21, No. 2,

1973.
GREENSPAN: DEVELOPMENTAL PERSPECTIVES 8 3

diffuse thinking, facile rationalization, extreme naivete, or action

orientation covering up ego defect.

Good

The organic ego apparatuses and basic ego functions are basically

intact. Interference from neurotic formations are minimal to none.

Fair

Either physical or psychological factors (neurological dysfunction,

functional ego defects, characterologic constrictions) moderately

impair the ego’s capacity.

Marginal

Same as above except they markedly interfere with ego’s capacity.

Inadequate

Either physical or psychological factors severely interfere with the

ego’s capacity (severe neurologic dysfunction, ego defects resulting

in psychotic processes, etc.).

2. Ego flexibility (vs. rigidity)

This category assesses the flexibility of the ego in its capacity to

utilize a variety of finely discriminated operations, in contrast to

the degree to which the ego is rigid, with only a few poorly discriminated operations at its disposal. Included are the capacities to

form and tolerate internal conflict and a variety of appropriate

affects as compared with signs of arrested ego development, ego

constrictions (severe character disorders), externalization of conflict, and altered or restricted modes of drive gratification (perversion). In addition, symptom formation which does not grossly interfere with ego functioning should be contrasted with symptoms or

affects which lead to a breakdown in ego functions or further constrictions (withdrawal).

Good

The ego is relatively flexible in its response to internal or external

stimuli. Neurotic formations only minimally interfere with this

flexibility.

Fair

The ego is somewhat rigid, but along with these ego constrictions is

a capacity to tolerate internal conflicts without marked disruptions

in ego functioning (mixed characterologic and neurotic difficulties).
8 4 PSYCHODYNAMICS OF DRUG DEPENDENCE

Marginal

The ego tends to be rigid in its operations. Neurotic formations

markedly intensify this rigidity and/or lead to minimal breakdowns

in ego functioning such as temporary losses of reality testing, loss

of sense of self, temporary loss of capacity to integrate thought and

affect, severe states of inhibition, or alteration of drive gratification.

Inadequate

The ego uses severe constrictions and only a few poorly discriminated operations (defenses) to cover more basic structural defects,

(as seen in psychotic or borderline organization).

3. Affects (multiple, flexible, developmentally advanced vs. few,

rigid, developmentally retarded)

This category should include an assessment of:

(a) The types of affects (those that predominate and those that

emerge under stress).

(b) Their developmental level. Are they developmentally immature ones like emotional hunger, fear, rage, jealousy, envy, or are

they developmentally more advanced ones like love, concern, empathy, anger?

(c) Their flexibility and selectivity. For example, are there

many affects potentially available, some of which can selectively be

called forth in the appropriate situation (fear and rage in one situation, love and empathy in another) or are there only a few (fear and

rage or pseudo warmth, which are used in most situations)?

Special attention should be paid to the type of anxiety manifested :

(a) Is it related to integrated internal structural conflict, signal

anxiety?

(b) Is it related to a combination of internal and external concerns (partial projection of fears onto the external world) or poorly

integrated internal conflict (a fear of the instincts)?

(c) Is it related to external concerns? Fear of castration, punishment, loss of love, separation, object loss, or of annihilation by the

object?

Good

There are a variety of rich, developmentally advanced affects which

are selectively used in response to external or internal stimuli as

well as conflict. Anxiety is related to internal integrated structural

conflict (signal).
GREENSPAN: DEVELOPMENTAL PERSPECTIVES 8 5

Fair

There is a capacity for advanced and selective use of affects when

not under stress. Anxiety is mainly signal, but other types are experienced under extreme stress.

Marginal

A few affects predominate and are representative of pregenital

concerns (emptiness, sadness, rage, envy, pseudo warmth). Anxiety

is related to fear of the instincts or pregenital external concerns,

separation, annihilation.

Inadequate

The affect system is not fully developed, resulting either in a lack

of affect (flattening or blunting) or an inappropriateness of affect.

Anxiety is related to external concerns, predominantly fear of

separation, object loss, and annihilation.

4. Defenses (developmentally advanced, stable, flexible, selective,

and effective vs. developmentally retarded, unstable, rigid, overly

generalized and ineffective)

This category should include an assessment of the general defensive

style and specific types of defenses or groups of defenses used, both

ordinarily and under stress. Included should be an assessment of:

(a) Their developmental level (primitive defenses such as projection, denial, introjection vs. developmentally advanced ones such

as sublimation and intellectualization)

(b) Their stability (what happens under stress)

(c) Their flexibility (how well they adapt to new situations)

(d) Their selectivity (can the most effective one be called forth

for a given situation?)

(e) Their effectiveness (do they respond to signal affects, bind

anxiety, and protect ego functions).

Because this is an important category which often reflects

general personality functioning, a number of defenses will be listed

and the rater is asked to evaluate the relative role of these or others:

avoidance, withdrawal, projection, introjection, undoing, acting

out, repression, identification, isolation, turning of emotions into

their opposites, reaction formation, sublimation, rationalization,

intellectualization, regression, and asceticism.

Good

The defenses are developmentally advanced and organized. They

protect the ego without significantly hampering its functions. For
8 6 PSYCHODYNAMICS OF DRUG DEPENDENCE

example, defenses involved in neurotic formations only minimally

interfere with memory (repressed memories) or ego flexibility

(repetitive reaction patterns).

Fair

The defenses are mixtures of developmentally advanced and immature defenses. Immature defenses are used mainly in response to

stress. Ego functions are only compromised under stress.

Marginal

The defenses are developmentally immature (preoedipal). They

hamper the ego markedly to moderately by constricting it (symptoms such as phobias, or characterological constrictions), leaving it

open to severe ranges of affects (anxiety, depression), or, in cases of

unusual stress, allowing disruptions in reality testing.

Inadequate

The defenses are primitive (mainly incorporation, projection, and

denial), unselective, and they severely hamper basic functions

(reality testing). At best they serve as only a fragile defense against

psychotic processes.

********

8. Relationship potential

This category should include an assessment of the individual’s

capacity for relationships with others. This would include an assessment of transference potential. The history of early object relationships, later relationship patterns, current patterns, and quality of

affect and relatedness in the interview situation should be used as

indicators.

Predominant aspects of relationship patterns should be assessed

-autistic, narcissistic, anaclitic, symbiotic, sadistic, masochistic,

phallic, sharing, loving, etc. Special attention should be paid to the

degree to which relationships are based on pregenital dyadic patterns

versus the degree to which they represent an integration of triangular Oedipal patterns.

Good

Relationship patterns reflect a capacity for intimacy and stability.

Pregenital traits are capable of being used in the service of genitality. There is a capacity for loving and sharing, along with capacities

for assertion, self- and social boundary setting, regression, etc.
GREENSPAN: DEVELOPMENTAL PERSPECTIVES 8 7

Fair

Relationships reflect some capacity for intimacy and stability, but

are compromised by pregenital patterns which emerge periodically.

Marginal

There are relationships, but they are markedly unstable and are

based on pregenital patterns.

REFERENCES

Bellak. L., ed. A Concise Handbook of Community Psychiatry and Community

Mental Health. New York: Grune & Stratton, 1964.

Bruch, H. Eating Disorders: Obesity, Anorexia Nervosa and the Person Within.

New York: Basic Books, 1973.

Greenspan, S.I. A consideration of some learning variables in the context of

psychoanalytic theory: Toward a psychoanalytic learning perspective.

Psychological Issues, IX, No. 1; Monograph #33, New York: Int. Univ.

Press, January 1975.

Greenspan, S.I., and Cullander, C.C.H. A systematic metapsychological assessment of the personality-its application to the problem of analyzability.

J Am Psychoanal Assoc, 21(2):303-327, 1973.

Mahler, M.S. Separation-lndividuation. Essays in Honor of Margaret S. Mahler.

John B. McDevitt and Calvin F. Settlage, eds., New York: Int. Univ. Press,

1971.

Mahler, M.S., and Furer, M. On Human Symbiosis and the Viscissitudes of

Individuation. New York: Int. Univ. Press, 1968.

Piaget, J. The Origins of Intelligence in Children. Translated by Margaret Cook.

New York: Int. Univ. Press, 1952.
CHAPTER 6

Self- and Object-Representation in

Alcoholism and Other DrugDependence: Implications for

Therapy

Henry Krystal, M.D.

For years, there was an anomaly in applying the psychoanalytic

approach to addictions. On the one hand it appeared that the

studies of some analysts, especially Abraham (1926), Simmel

(1930, 1948) and Rado (1926, 1933), contributed insight into the

psychodynamics of the drug-dependent individual. Although as

analysts we continued to find evidence in psychotherapy with alcoholics that these early formulations regarding the nature of important unconscious fantasies of the patients were basically correct, the

degree of success in analytic treatment of addicts was minimal. One

simply could not proceed to treat the drug-dependent person in the

classical psychoanalytic fashion by simply amending the list of

one’s interpretations with those pertaining to the oral character.

The patients did not stay in treatment.

In my previous study of this problem, I came to the conclusion

that there were two major areas in which drug-dependent individuals required special consideration and modification of treatment:

the problems of regression in the nature of affects and affect tolerance, and certain characteristics of the drug-dependent individual

self-representations and object-representations (Krystal and Raskin

1970). Elsewhere I have discussed the modifications of psychotherapy which are necessary to help the drug-dependent person to

improve his affect tolerance, and start the process of affect verbalization (Krystal 1973). I consider this to be an indispensable preliminary phase of treatment for drug-dependent individuals.

88
KRYSTAL: SELF- AND OBJECT-REPRESENTATION 8 9

This paper is concerned with the transferences, and therefore also

the nature of self- and object-representations in the drug-dependent

patient. First, let us look at the commonplace statement: “The

object-relations of the addict are ambivalent.” What is the effect of

this situation on the psychotherapy? Aggression is difficult for such

a patient to handle. Because of the prevalence of magical thinking,

fortified by the wish for magical powers, and in harmony with a

grandiose self-representation, alcoholics in psychotherapy become

terrified of their death wishes directed toward the therapist. At

some point in treatment they are confronted with their extraordinary envy and have the need to deal with their poorly mastered

narcissistic rages. At this point, they flee from treatment, because

they fear that their death wishes will destroy their therapist. Alternately, they tend to turn their aggression against themselves, and

act it out in an accidental injury, suicide attempt or relapse of

drinking (Simmel 1948). This may be one of the major reasons why

alcoholics and drug abusers do poorly in individual therapy. For

those alcoholics with whom individual therapy is desirable, a clinical situation works better in which auxiliary therapists are made

available. As additional contacts are usually readily available in a

clinic, they may be observed to be spontaneously sought by some

patients with addictive problems.

The idea of using a team to manage the alcoholic patient is not

new. One of the successful psychoanalytic treatment centers was

Simmel’s Schloss Tegel Clinic (Simmel 1948). Simmel was concerned with the alcoholic’s tendency to self-punishing ideas and suicide attempts after withdrawal. The patient who was being withdrawn from alcohol was permitted to stay in bed, and a special

nurse was assigned to look after him, including his diet. This was a

conscious attempt to provide the patient with passive gratification,

to provide a gentle “weaning” and prepare the patient for his

“regular analysis” (Szasz 1958).

It has been my observation that when highly ambivalent patients

have a therapeutic team available, they will use it for the purpose of

“splitting” their transferences. In this way they experience their

angry and destructive wishes toward one member of the team while

presenting a basically loving relationship toward another, preferably

the chief therapist (Krystal 1973). I believe that this happens all the

time in treatment clinics and groups. However, most of the time the

transferences acted out with various clinic employees will be unrecorded in a description of the therapeutic process unless a special

effort is made to “gather” these. If everyone in the clinic reports to

the chief therapist about every contact and communication with

the patient, the picture of the nature of the patient’s transference
9 0 PSYCHODYNAMICS OF DRUG DEPENDENCE

may then be put together. It will be found that the patient is not

experiencing a simple splitting of the transference into one love and

one hate relation. The picture will be quite complex, and quickly

changing. At one moment, the chief therapist may be experienced

as the idealized mother whose love and admiration he yearns for,

while another staff member may be experienced as a rejecting, condemning parental image whom the patient dreads and hates; and

still another staff member may be experienced as seductive, intrusive, destructive or other parental transference object. When the

patient feels frustrated by the chief therapist, and needs to experience his rage toward him, instantly he will experience one of the

other members of the team as an idealized parent, while he experiences other partial transferences with yet another clinic staff member-anybody around, whether in a therapeutic role or not. In order

to demonstrate to the patient the ambivalent nature of his transference, it is necessary to bring his projections together and show that

all of these transferences represent various object-representations,

which he needs to experience toward the one therapist. The patient’s vacillations and changes in attitudes toward the various staff

members can be used to demonstrate his dilemma. Demonstrating

the ambivalence in the transference is the crucial step in working

with alcoholics, because one of the major forces which propels

individuals toward addiction is that they can displace their ambivalence toward the drug. Szasz (1958) has emphasized this aspect of

drug problems in his paper on the counterphobic attitude in drug

dependence.

A special instance of transference splitting may occur when an

alcoholic is sent to the clinic by a court. The probation officer

assigned to the patient may become the object of transference of a

very significant type. The fact that this type of a patient has a characterological defect, which requires that he “externalize” (that is,

fail to integrate) his superego function so that others enforce controls for him, indicates that these transferences cannot be left out

of the treatment (Margolis et al. 1964).

In 1931, Glover commented that drug-addicted patients are able

to give up the drugs up to the very last drop. This “last drop”

however, becomes virtually impossible to give up, because it contains the symbolic expression of the fantasy of taking in the love

object (Glover 1931). The external object is experienced as containing the indispensable life-power which the patient wants to but

cannot “internalize.” This is the basic dilemma dominating the

psychic reality of this type of patient. This externalizing tendency

applies to his conscience as well, so that he is unable to experience

it as being a part of himself but arranges for others to exercise it for
KRYSTAL: SELF- AND OBJECT-REPRESENTATION 9 1

him. In the use of Antabuse, we see that the fantasy solution of

swallowing the object refers not only to “goodness” or narcissistic

supplies, but swallowing an external source of impulse control in

quite a concrete way. The failure to integrate one’s own functions

and aspects such as conscience, and attributing it to others, such as

parents, spouses or probation officers makes the drug-dependent

individual experience the world in a paranoid way. Thus, Glover

remarks that drug addicts are inverted paranoids, and that they are

both the persecuting and persecuted ones (1931). Whether there is

a probation officer or Antabuse or similar substances (or procedures) used by the therapist, the transferences, involved in the patient’s failure to see his projection of his own superego onto the

external object, have to be brought into the treatment by interpretation. Otherwise the patient is never going to be able to accept

himself as a whole person.

I have been talking about what I consider to be the basic defect,

the basic dilemma in the life of the drug-dependent individual, such

as the alcoholic. It is that he is unable to claim, own up to and exercise various parts of himself. He experiences some vital parts and

functions of his own as being part of the object-representation and

not self-representation. Without being consciously aware of it, he

experiences himself unable to carry out these functions because he

feels that this is prohibited for him, and reserved for the parental

objects. I have studied and described the clinical evidence for these

views elsewhere (Krystal and Raskin 1970; Krystal 1975). Let me

illustrate with something that is familiar to all of us: All of us experience similarly those parts of ourselves under the control of the

autonomic nervous system, which includes all of our affective

expressions. We all consider these huge areas of ourselves as not

being under our own control. Numerous experiments in recent

years have demonstrated that through biofeedback devices one can

learn to acquire conscious control of these parts. However, a surprising. finding came up in our work with biofeedback combined

with psychotherapy. In the psychotherapeutic relationship, we received information ordinarily lost in the biofeedback situation.

Some patients experienced great anxiety over gaining control over

these parts of themselves which they experienced as not meant for

them. Their unconscious scheme of things was that organs such as

their hearts were under the special care of God (or fate, doctor,

hospital and the like) who guaranteed their survival. This is illustrated in an old-time, primitive theory of sleep-namely that God

causes it by taking away the soul, which He may by His grace return

to us, the next morning. This theory of sleep is a transference of the

maternal image for whom lifegiving powers, as well as nursing, are
9 2 PSYCHODYNAMICS OF DRUG DEPENDENCE

reserved. This view has its roots in infancy, and even phylogeny, for

certain newborn mammals will not even void unless licked by the

mother (Kirk 1968). Thus, the mothering includes a permission to

live by exercising certain vital functions. When the patients were

told that they could be taught to control their autonomic functions, some experienced fears that taking over such maternal prerogatives would cause them to destroy themselves. Of course, even

dying is viewed by some as being regulated by the mother who

takes back her child (e.g., Mother Earth, or the Pieta theme) and it

is a sin for one to usurp the right to end one’s own life.

The reader may think I am jumping to conclusions and that biofeedback simply demonstrates a process of learning. Once the

preceptive range is augmented by the apparatus, one can control

extended parts of oneself. This is, of course, the learning theory as

applied to biofeedback activities (DiCara 1972; Krystal 1975). But

let us reexamine this premise. Experiences with hypnosis and

placebo show that a subject has the potential to exercise these

autonomic functions right away and that they are therefore not

learned but are unutilized existing capacities. What happens under

the influence of the hypnotist or the placebo which gives an individual the ability to exercise control over parts of himself he has

hitherto reserved for his maternal transference objects?

There is a temporary lifting of internal barriers between the

self-representation and the object-representation, thereby permitting access to, and control of, parts of oneself previously “walledoff.” The walls curtain repressed parts of one’s self, deprived of the

conscious recognition of selfhood. This does not pertain just to

parts of one’s body but much more so to spheres of functions.

Thus, just as biofeedback subjects may be reluctant to control

autonomic nervous system functions even when they consciously

desire it, so drug-dependents may not want control of appropriate

self-functions.

Repressions take place at various times in childhood in connection with the various conflicts centered in psychosexual development. A boy who finds himself frightened of his competitive

strivings with his father because of his fantasies and theories of

destroying his father and taking his place (becoming the father)

may repress these wishes and fantasies. Thereafter he may see himself as a boy, with adult masculine modes of action reserved for the

father. Unless he finds some way to overcome or get around these

repressions, he may never be able to fulfill his masculine ambitions,

or consciously own up to, or exercise his masculinity. This would

lead to the kind of inhibition in occupational and sexual goals, with

a rise to prominence of homosexual striving which the early psycho-
KRYSTAL: SELF- AND OBJECT-REPRESENTATION 9 3

analytic writers described many times in their observations of

alcoholics (Abraham 1926; Simmel 1930, 1948; Rado 1926, 1933;

Juliusberger 1913; Hartmann 1925). In some homosexuals, the

fantasy is that through the sexual act one will regain an alienated

masculinity attributed to one’s “others.”

However, in drug-dependent individuals it is the “walling-off” of

the maternal object-representation, and within it self-helping and

comforting modes, which is the specific disturbance. Thereby, the

alcoholic loses his capacity to take care of himself, to attend

to his needs, to “baby” or nurse himself when tired, ill or hurt

narcissistically.

In the relationship between the infant and the mother, the child

gradually takes over certain functions from the mother by identification with her. Where the relationship with the mother is very

troubled for the child, the maternal function becomes rigidly reserved for the mother and is experienced as prohibited for him.

Some drug-dependent individuals fall into this category. But even

where the relationship with the mother is good, the mother must,

in addition to providing the model, communicate to the child the

permission to take over these functions. An example of a type

mother who has difficulty in permitting this can be observed in the

nursery where some mothers become “jealous” of the child’s transitional object, and punish the child or prevent its use for selfcomforting. Those things which the child does to comfort himself,

from thumbsucking to masturbation, each provide an occasion for

communication of the permissibility of utilizing self-comforting

modes of behavior. When a person feels that he cannot (actually

may not) exercise these functions, he feels envious of his mother,

and other women, and transference objects, e.g., doctors, and

yearns to gain them symbolically or magically.

Therein is the source of the drive by the alcoholic to use the

drug, both as a pharmacological means to manipulate his affective

states and as a placebo, to gain surcease from his feelings of depletion resulting from the repression1

 of self-helping attributes and

functions of his own by making it part of a rigidly walled-off

object-representation. We must recognize and acknowledge that the

kind of person who is likely to become drug dependent is one who

uses the drug to help him carry out basic survival functions which

1

I have discussed elsewhere the concept of repression as referred to in this

context. It extends the definition of elements repressed from those rendered

unconscious, to include those alienated: not consciously recognizable as part of

one’s self and one’s own living (Krystal 1973).
9 4 PSYCHODYNAMICS OF DRUG DEPENDENCE

he otherwise cannot do. People who drink in order to be able to .

continue to work, thus gain access to their assertive, masculine,

paternal modes of behavior. People who drink for the purpose of

surcease and comfort obtain their goal, in addition to the pharmacological effects, by gaining access and ability to exercise their

maternal functions. The longing to regain alienated parts of oneself is the real meaning behind the fantasies of fusion with the good

mother so clearly discernible in drug-dependent individuals (Chessick

1960; Savitt 1963).

These yearnings make their appearance in the transference in

psychotherapy with alcoholics and other drug-dependent individuals, and in this phase of the treatment, the phenomenon has been

termed by Fenichel “object addiction” (1945). This transference

needs to be interpreted in psychotherapy for the same reason that

all transferences need to be interpreted: So that the patient will discover that the characteristics which he attributes to the analyst

(psychotherapist) are actually his own mental representations which

he first perceived as being part of his mother, and now reexperiences again, attributing them to the therapist. The healing principle

of psychoanalysis consists in the patients claiming their own mind,

restoring the inviolable unity of their own selves.

But, as we know too well, patients do not feel free to do this.

They fight it with all the means at their disposal, as if their lives

depended on maintaining the repressions. And of all patients, drugdependent individuals have the worst struggle with this part of

treatment. When we try to understand the nature of their psychic

reality, which made the removal of repression of their maternal

object-representations so difficult for them, we discover that it

leads to care of their emotional problems derived from infantile

traumata.

However, first let us step back and take another look at one

aspect of drug addiction so obvious that we take it for granted, and

thereby miss an essential clue to the nature of the intrapsychic conflict in alcoholism as well as other related states. Drug abuse consists in fact, not only of taking drugs, but equally important, being

deprived of drug effect. Drugs which are addicting are short acting.

The longer acting the drug, the greater the likelihood of the user

panicking and developing a “bum trip” (Krystal and Raskin 1970).

Withdrawal from drugs is an integral part of the process of

addiction (Krystal 1962). The development of ever-increasing tolerance for the drug is greater and faster in drug-dependent individuals

because they have the need to deprive the drug of its power (Krystal

1966), at the same time, the moment it does lose its force, they

panic (Rado 1933; Krystal 1962).
KRYSTAL: SELF- AND OBJECT-REPRESENTATION 9 5

What is the meaning of all of these apparent contradictions? It is

that while the drug-dependent yearns for the union with his maternal love object (representation), he also dreads it. He really can’t

stand it either way. Schizophrenic patients and some borderline

individuals yearn for union with their love object (representation)

and once they achieve it (in fantasy), they cling to it passionately,

giving up conscious registration of all contacts with whatever might

spoil it.

Drug-dependent individuals are very busy getting the drug, but

can feel themselves reunited with the idealized love object only

rarely for short periods of time, and only at moments when they

are virtually totally anesthetized. And even then, one finds with

amazement that many of them—at the very moment of the climactic action of the drug-indulge in acts of riddance, such as moving

bowels, vomiting, cleaning their bodies, cutting their nails, or even

house cleaning (Chessick 1960). It may be said that they are addicted

to the process of taking in and losing the drug rather than to having

it. The seemingly bizarre behavior of the drug addict who plays

with the drug by “regurgitating” it back and forth between the

syringe and vein suddenly falls into place here.

Drug-dependent individuals dread fusion with the love object

representations because of the way they experienced them in the

formative period of their lives. Their mothering was unsatisfactory,

with resulting severe psychic traumatization in infancy, and many

and wide-ranging damaging effects to their personalities. As a result,

whatever one looks for, one finds.

When the early analysts were fascinated by their discovery of the

psychosexual development, they found that alcoholics were fixated

on the oral level (Abraham 1954). When they paid attention to the

nature of unconscious fantasies, they discovered yearning for union,

as well as persecutory fears (Simmel 1948; Rado 1926; Szasz 1958).

When they became aware of the role of homosexual striving in the

genesis of emotional problems, alcoholics were found to have them

and dread them (Hartmann 1925). When they became aware of

characterology, alcoholics were found to be schizoid characters

(Simmel 1930), in addition to the earlier classification of them as

oral characters. When they started paying attention to ego functions, these were found to be impaired as well (Savitt 1963).

I have made two additions to this wealth of views of the nature

of psychological disturbances of drug-dependent individuals:

(1) I have found that as a result of massive childhood psychic

trauma, these individuals experienced arrest in affect development

and an impairment of affect tolerance (Krystal 1970, 1974, 1975).

These produce, in effect, a fear of feelings, and need to block them.
9 6 PSYCHODYNAMICS OF DRUG DEPENDENCE

(2) I found that in order to survive, some drugdependent individuals had to repress their rage and destructive wishes toward their

maternal love object. This manifests itself in a rigid “walling-off” of

the maternal love object representation, especially with an idealization of it, and an attribution of most of life-supporting and nurturing functions to it. By doing this, the patient manages (in his

fantasy) to protect the love object from his fantasied destructive

powers, and assure that “someone out there” loved him and would

take care of him (Krystal and Raskin 1970).

But the repressed aggression never disappears, and so the alcoholic and other drug addicts dread that if they accomplish fusion

with the love object they will destroy it, and thereby return themselves to a traumatic situation, which they dread. One clinical

observation well known to every worker in this field supports the

accuracy of these constructions: Patients are unable to accomplish

normally the work of mourning and the feeling of “introjecting”

the lost love object. The introjection fantasy is a form of partial

union of the self-representation and object-representation, which

most people achieve at the end of mourning. It is a clinical commonplace to say that alcoholics and other drug-dependent individuals

cannot tolerate object losses (and that includes therapists) without

being so threatened with their own affects that they have a virtually

unavoidable relapse to self-destructive drug use.

This is the dimension of the problem of ambivalence which

makes its appearance in psychotherapy with alcoholics. In the early

stages of therapy the very availability of an object creates serious

challenges to the patient. There is the already mentioned fear of

aggressive impulses and wishes. There is, in addition, the problem

stressed by Vaillant (1974), that when alcoholic patients ideaiize

their therapists in the transference, they experience themselves as

worthless and bad.

But these are just preliminaries. The greatest difficulty is that

effective work in (intensive, psychoanalytically oriented) psychotherapy, through which one can give up attachment to infantile

object-representations and the infantile view of oneself, is by

“effective grieving,” a process analogous to mourning (Wetmore

1963). That very process spells trouble for the drug-dependent

patient, who tends to dread being overwhelmed with depression,

which represents to him the return to childhood trauma. Raskin

and I postulate, in order to explain this phenomenon, that this

type of individual has had a nearly destructive childhood trauma

experience, which he fears may return, and which he experiences as

a “fate worse than death” (Krystal and Raskin 1970). Elsewhere I

have discussed the technical modifications made necessary by re-
KRYSTAL: SELF- AND OBJECT-REPRESENTATION 97

gression in the nature of affects and impairment of affect tolerance.

If even that obstacle is overcome, and the patient is able to grieve

effectively, then he faces the ultimate challenge: the conscious

acceptance of his object-representations as his own mental creations.

At the end of a successful analysis one is in the same position as at

the end of the hypothetical completely successful mourning. The

bereaved person discovers that though the lost person is dead and

gone, he continues to exist in the survivor’s mind. This gives him

the opportunity to discover that as far as he is concerned, that is

where the object had been all along-in his mind as an objectrepresentation of -his own creation. And so one has to face the

“return of the repressed.” All the “bad” persecutor-y aspects of the

object could be viewed as projections, but they are really simply

fantasies, impulses, wishes and feelings which were not integrated.

In other words, the giving up of the repressions, the owning up to

the self-sameness of one’s object-representations confronts one with

the aggression which caused the alcoholic to “wall-off” his objectrepresentation so rigidly, and subsequently to develop that tragic

yearning and dread of the love object.

Earlier. I said that the rigid “walling-off” of the maternal objectrepresentation took place in the face of extreme aggressive impulses

toward it. The evidence for that came from this stage of the psychotherapeutic work with drug-dependent individuals. The intensity of

the narcissistic rages, the persistence of the aggressive impulses

make one wonder if all addiction is, at bottom a “hate-addiction.”

The problem of aggression and its apparent threat to the safety and

integrity of the self-representation and/or object-representation sets

the limits to the kinds and numbers of drug-dependent patients who

can be carried to completion of psychotherapy. Along the way

most such patients, when confronted with their aggression, will

relapse again and again into drug use and self-destructive activities.

Others will be driven to prove that their childhood misfortunes

were real, by getting the therapist angry and provoking abuse. Still

others become so terrified of the dangerous, poisonous transference

object, that they set out on a panicked, frantic search for the ideal

mother in some form-such as drink, love or gambling. If the therapist is otherwise equipped to bear the disappointments, provocations and failures entailed in working with these patients, and has

the time and patience to permit the patient to do this work by

minute steps, then it is helpful to keep in mind that the patient is

confronted with problems of aggression that make him experience

the transference as a life-and-death struggle. Care and caution must

be exercised that the patient not be overwhelmed with his aggressive

feelings, or guilt. Emergencies in which the patient’s life hangs in
9 8 PSYCHODYNAMICS OF DRUG DEPENDENCE

the balance will occur, for that may be the way the patient may

have to test the therapist.

When Simmel reviewed his lifetime experience with alcoholics in

a paper which he never completed, he was very clear about the

problems of aggression in the treatment of these patients. He said:

. . . during a state of abstinence under psychoanalysis in a hospital,

substituting for the addiction to alcohol or drugs was an overt suicidal

addiction or an overt addiction to homicide. During this stage the

addict’s only compulsion is to kill: himself or others. Usually he does

not rationalize this urge; he just wants to die or, at other times he just

wants to kill (Simmel 1948, p. 24).

The aggression observable in the self-destructive lifestyle of the

drug-dependent individual is, in the process of psychotherapy,

traced to its ultimate sources and meanings. In this process the patient has to be able to experience with the therapist that which he

has never dared to face-his hatred. Instead of seeing himself as a

victim, and claiming innocence, now he confronts his murderous

aggression. To do so, however, requires giving up the treasured view

of oneself as the innocent victim, which again, has to be mourned.

And so, it can be said that an unavoidable step in the treatment of

a certain type of drug-dependent individual in intensive therapy is a

depressive stage. During this phase of the treatment the dependence

upon the therapist is extreme, and no substitutes are acceptable.

While early in the treatment many patients do best in a clinic with

multiple therapists, for the few who will be carried to this type of

therapeutic completion, the chief therapist has to be the one who

will be stationary and available to the very end.

Such are some of the difficulties resulting from the nature of

object-representation in addictive personalities. They determine

that successful psychoanalytic psychotherapy will continue to be

the exception, mainly of research interest.

SUMMARY

The nature of the object relations of the drug-dependent patient

is such that he craves to be united with ideal object, but at the

same time dreads it. He thus becomes addicted to acting out the

drama of fantasy introjection and separation from the drug. There

is a corresponding intrapsychic defect; certain essential functions

related to nurturance are reserved for the object-representation.

The objective of therapy is to permit the patient to extend his conscious self-recognition to all of himself, thereby freeing him from

the need for the placebo effect of the drug as a means of gaining

access to his alienated parts and functions.
KRYSTAL: SELF- AND OBJECT-REPRESENTATION 9 9

REFERENCES

Abraham, K. The influence of oral erotism on character formation. In: Selected Papers of Karl Abraham. New York: Basic Books, 1954.

The psychological relation between sexuality and alcoholism. Int J

Pychoanal, 7:2, 1926.

Chessick, R.D. The pharmacogenic orgasm. Arch Gen Psychiatry, 3:117-128,

1960.

Clark, L.P. Psychological study of some alcoholics. Psychoanal Rev, 6:268,

1919.

DiCara, L. Learning mechanisms. In: Biofeedback and Self-Control. Chicago:

Aldine, 1972.

Fenichel, O. The Psychoanalytic Theory of the Neuroses. New York: Norton,

1945.

Glover, E. The prevention and treatment of drug addiction. Br J of Inebriety,

29:13-18, 1931.

Hartmann, H. Cocainismus und homosexualitat. Z Neur, 95:415, 1925.

Juliusberger, 0. Psychology of alcoholism. Zentralblatt fur psychoanal, 3:1,

1913. Abstract in Psychoanal Rev, 1:469, 1913-14.

Kirk, R.W. Pediatrics. In: Canine Medicine, Earl J. Catcott, ed. Santa Barbara,

CA: Amer. Vet. Pub., Inc., 1968, p. 809.

Krystal, H. The physiological basis of the treatment of delirium tremens. Am J

Psychiatry, 116:137-147, 1959.

The study of withdrawal from narcotics as a state of stress. Psychoanal

Q Suppl, 36:53-65, 1962.

Therapeutic assistants in psychotherapy with regressed patients. In:

Current Psychiatric Therapies, J. Masserman, ed., 1964, p. 232.

Withdrawal from drugs. Psychosomatics, 7:199-302, 1966.

Technical Modification in Affect Regression and Impairment of Affect

Tolerance. Paper presented at the Annual Meeting of the American Psychoanalytic Association, 1973.

Psychic Reality. Paper presented to the Michigan Psychoanalytic

Society on March 1, 1973. Mimeographed.

The genetic development of affects and affect regression. Part I. The

Annual of Psychoanalysis, Vol. II, 1974.

The genetic development of affects and affect regression. Part II.

Affect tolerance. The Annual of Psychoanalysis, Vol. III., p. 179-219,

1975.

Krystal, H. and Raskin, H.A. Drug Dependence: Aspects of Ego Function.

Detroit: Wayne State Univ Press, 1970.

Margolis, M., Krystal, H., and Siegel, S. Psychotherapy with alcoholic offenders.

Q J Alcoh, 25:85-99, 1964.

Rado, S. The psychic effect of intoxicants: An attempt to evolve a psychoanalytic theory of morbid craving. Int J Psychoanal, 7:396-413, 1926.

(Also in: Psychoanalysis of Behaoior. New York: Grune & Stratton, 1956.)

The psychoanalysis of pharmacothymia. Psychoanal Q. 2:1-3, 1933.

(Also in Psychoanalysis of Behavior.)

Savitt, R.A. Psychoanalytic studies on addiction: Ego structure in narcotic

addicts. Psychoanal Q, 32:143-57, 1963.

Simmel, E. Morbid habits and cravings. Psychoanal Rev. 17:48-54, 1930.

Alcoholism and addiction. Psychoanal Q, 17:6-31, 1948.
100 PSYCHODYNAMICS OF DRUG DEPENDENCE

Stoyva, J. The public (scientific) study of private events. In: Biofeedback and

Self-Control, Barber, T.X., ed. Chicago: Aldine, 1970.

Szasz, T.S. The counterphobic mechanisms in addiction. J Am Psychoanal

Assoc. 6:309-325, 1958.

Vaillant, G. Paper on The Treatment of Alcoholics in the Cambridge Alcoholic

Clinic. Given at a Symposium on Alcoholism, Boston Univ, 1974.

Wetmore, R.J. The role of grief in psychoanalysis. Int J Psychoanal, 44:97-

103, 1963.
CHAPTER 7

The Ego, the Self, and Opiate

Addiction: Theoretical and

Treatment Considerations

Edward J. Khantzian, M.D.

INTRODUCTION

Until recently, the psychoanalytic literature on addiction stressed

the pleasurable aspects of drug use to explain the compelling nature

of addiction (Abraham 1960; Freud 1955; Rado 1933, 1957).

Although Rado and others (Fenichel 1945; Savitt 1954; Wikler and

Rasor 1953) appreciated underlying factors of depression, tension,

and anxiety, many of these same workers continued to place particular emphasis on the euphoric-pleasurable aspects of drug use.

Most of this literature on addiction focuses on the regressive gratification of libidinal instincts achieved through the use of addictive

substances. Glover’s work stands in striking contrast to the other

theoretical explanations of addiction. He stressed that addicts used

their substance progressively (as opposed to regressively) to defend

against primitive, sadistic impulses and to avoid psychosis. He

seemed to appreciate better the enormous difficulties addicts have

with their aggression and viewed the sexual and pleasurable aspects

of drug use as defensive responses to the underlying problems with

aggression (Clover 1956).

More recent works (Chein et al. 1964; Khantzian 1974a. 1974b,

1975; Krystal and Raskin 1970; Milkman and Frosch 1973; Wieder

and Kaplan 1969; Wurmser 1974) have stressed the adaptive use of

drugs and have tried to incorporate a better appreciation of how the

psychopharmacologic action of the different drugs interacts with

the personality organization of addicted individuals. These reports

have focused on ego functions and ego impairments, and in particu101
102 PSYCHODYNAMICS OF DRUG DEPENDENCE

lar on problems which affect tolerance (Krystal and Raskin 1970;

Wurmser 1974) and drive defense (Khantzian 1974.c). Zinberg (1975)

has stressed the importance of setting and how it interacts with ego

function and drug effect. Some of these reports have also tried to

take into account narcissistic problems that contribute to the individual’s general predisposition to addiction, and to some of the related specific ego impairments and psychopathology that are evident

in addicted individuals.

In this report I will selectively review and expand on recent theoretical and clinical investigative work that has focused on the ego

impairments of narcotic addicts, particularly in relation to problems

of affect and drive defense. I will also attempt to explore how certain problems with self-care and self-regulation are related to failures in internalization, and how these failures in development leave

such individuals vulnerable to a whole range of hazardous behavior

and’ involvements, but in particular to addictions. Finally, an

attempt will be made to examine certain unique and characteristic

traits which are related to narcissistic processes and defense so common among addicts. These characteristics serve to compensate for

their developmental impairments, but at the same time impede such

individuals in establishing and obtaining sufficient satisfactions in

their involvement with people, work and play. On the basis of these

theoretical considerations, some implications for treatment interventions will be explored.

AFFECT AND DRIVE DEFENSE

In working with narcotic addicts one often hears the claim that

they are psychologically “healthier” than other types of addicts or

psychiatric patients. Such claims are bolstered by arguments that

one would have to be healthier and “better put together” to survive

the challenges and dangers involved in obtaining the money and

drugs to support an addiction to heroin. Such claims are based on

observations of how successful such individuals seem to be in acting

upon and extracting from their surroundings what they want for

themselves. This apparent “success” distracts both the observer and

the addict from indications of failure in functioning that are often

equally as apparent, namely, the addict’s inability to cope with his

emotions and his relations with other people. The so-called “successful” functioning of the heroin addict says less about his/her

mental health than about how the ego of such individuals is shaped

and developed along certain lines to serve their addiction and

related requirements. However, we also suspect that these special
KHANTZIAN: EGO, SELF, AND OPIATE ADDICTION 103

qualities of addicts represent attempts to make up for and to offset

major deficits, impairments and failures in defense against their

affects and drives.

We believe these failures and deficits in defense are developmental and are intimately related to problems with internalization.

Internalization is a process by which the developing infant and child

acquires qualities and functions from parental figures in the process

of maturation. Ideally, the person eventually can care for himself as

a result of this internalization. This process is probably related to the

ways in which the developing person is exposed to the “good

enough (caring) environment” and how “the good enough mothering” in infancy and childhood gets into the person as a function of

adequate nurturing (Winnicott 1953). If successful, this process of

internalization establishes within the person a coherent sense of the

self, an appreciation of the separate existence of others, as well as

the establishment of adequate ego functions that serve purposes of

defense and adaption. In this section, I will focus on those aspects

of internalization related to ego mechanisms of defense, especially

against affects and drives, and we will stress particularly ego impairments and problems associated with drive and affect defense in

narcotic addicts.

Based on direct child observation, and clinical practice with

adults, there is rather convincing evidence that normal development

requires certain amounts of frustration (Kohut 1971; Mahler 1968;

Meissner, Mack, and Semrad 1975; Winnicott 1953). Optimally,

extremes of deprivation or indulgence are avoided and the child is

confronted with enough tolerable disappointment that a capacity to

tolerate emotional distress and pain is gradually built up. To summarize how this capacity evolves, the individual gradually incorporates into a sense of the self and into the ego the parents’ protective

role and their function as a stimulus barrier. Used in this sense,

“stimulus barrier” refers to those aspects of ego functions that

operate either to maintain a minimal level of unpleasant affects or

tension, or to defend against such feelings through appropriate

action and mechanisms of defense when they reach high or intolerable levels.

Krystal and Raskin (1970) have traced how affects also develop

along certain lines and serve the ego to defend against internal emotional states and drives. They have delineated in a most helpful

way how anxiety and depression develop out of a common undifferentiated matrix, and evolve through differentiation, desomatization and verbalization. Ideally, this process of development

ultimately allows the person to use feelings as a guide and signal to
104 PSYCHODYNAMICS OF DRUG DEPENDENCE

mobilize the ego in response to the constant barrage of internal

and external stimuli involved in human living. They further review how trauma in the course of development (or as a result of

catastrophic events later in life) may lead to both affective disturbances and drug dependence. They stress how traumatization produces a reversal and regression resulting in de-differentiation of

affects. In addition to trauma, they also stress how the failure of

parents to act as adequate models in managing affects leads to an

arrest in development, which precludes successful differentiation.

In the case of addicts, a major consequence of such development

arrest is that they are unable to make use of anxiety and feelings as

signals or guides because their feelings are undifferentiated and

overwhelming.

Krystal and Raskin are fully aware of the specific anesthetic

action of heroin on painful affects and explain most cogently why

individuals involved with heroin are subject to and are unable to

manage overwhelming affect states. However, in my estimation,

they do not sufficiently distinguish the action of opiates from other

sedatives and alcohol. In addition to its antiaggression action, I

believe that the capacity of heroin, specifically, to relieve overwhelming, distressful affect states is what makes it such a compelling substance for narcotic addicts. This observation might seem to

state the obvious, but to specify and more precisely define what

affect states are relieved by heroin and other drugs has most important implications for management and treatment, especially

with psychotropic drugs.

Kohut (1971) has traced how problems with internalization are

linked to narcissistic disturbances, and in particular, how such disturbances lie at the root of addictive disorders. A child’s traumatic

disappointments with the mother because of her lack of empathy,

her failure to act as an adequate stimulus barrier or to provide adequate stimuli and gratification of tension, lead to a failure in development of the child’s psychic apparatus. Later in life many of these

individuals discover that drugs substitute for defects in their ability

to cope with inevitable life distresses and disappointments. Kohut

makes the provocative statement, “the drug-serves not as a substitute for loved or loving objects, or for a relationship with them, but

as a replacement for a defect in the psychological structure” (p. 46)

(emphasis added). Wieder and Kaplan (1969) similarly appreciate

this aspect of drug use referring to drugs as a “corrective-and

prosthetic.” Wurmser (1974) comes to the same conclusion, referring to the addict’s “defect of affect defense.” He emphasizes the

addict’s enormous difficulties in handling painful affects, and how

opiates in particular act to relieve feelings of narcissistic rage,
KHANTZIAN: EGO, SELF, AND OPIATE ADDICTION 105

shame, hurt, and loneliness. In lieu of adequate defenses, Wurmser

speculates that narcotics act by damping such feelings directly and/

or raising the threshold against reactions of narcissistic disappointment.

A recent case example highlights nicely some of the problems

with internalization and defects in affect defense that have been

reviewed thus far:

A 29-year-old male was struggling with much rage and

anxiety. Despite all good intentions, he found himself reverting to previous addictive behavior. His reversion had

occurred in the context of a visit from his mother, whom he

had not seen in over a year. She had reprimanded him about

some recent financial indiscretions that concerned her, but

had totally failed to appreciate how anxious, fragmented,

and overwhelmed he was feeling at the time. The painful

consequences of the defects in his ego structure and the

quality of the overwhelming feelings in the absence of such

structure were poignantly conveyed in the account of his

reactions to his mother’s visit. He also gave some hints

about how such deficits originate in parental attitudes and

disappointment. He complained-“My mother is utterly disregarding. She doesn’t know me at all-what I feel or think

or what I’m like. When I feel anxious, I feel it all over, not

just butterflies in my stomach or sweaty hands. I feel it all

over. When I get anxious, I get anxiouser, and anxiouser and

anxiouser. When I get afraid, the only thing that makes it go

away-” and then he struggled to explain, and finally

offered-“is a stronger person.” In this context he pleaded

that the therapist prescribe a medication for his anxiety.

In my own work with narcotic addicts, I have been impressed

with the lifelong difficulties such individuals have had with aggression and derivative problems with rage and depression. After obtaining repeated histories from addicts about how dysphoric feelings

associated with restlessness, anger and rage were relieved by heroin

and other opiates, and after observing narcotic addicts stabilize on

methadone, I began to suspect that narcotics might have a direct

antiaggression action. In a previous report (Khantzian 1974a) I

summarized these findings and concluded that problems with

aggression predisposed certain individuals to dependence on opiates and played a central role in the development of addiction. I

stressed the addict’s use of the antiaggression action of opiates in

the service of drive defense, and formulated how the longer but

same action of methadone was the basis for “success” of methadone maintenance. In the report cited and elsewhere (Khantzian

1972), we stressed the disorganizing influence of aggression on ego

function in individuals whose ego stability was already subject to
106 PSYCHODYNAMICS OF DRUG DEPENDENCE

dysfunction and impairment either as a result of developmental

arrest or regression.1

Although our own work with narcotic addicts has stressed problems with drive defense, particularly in relation to aggressive drives,

it is important to note and emphasize that all the more recently

cited reports of clinical investigative work with narcotic addicts are

remarkably consistent with each other. They stress problems with

drive and affect defense and focus on developmental impairments

in the ego. More remarkable, much of this consensus has been

arrived at almost simultaneously and independently. I believe that

further work on the “ego side” of the problem, with cross fertilization of thinking among various investigators promises to yield

further understanding of the relationship between drive and affect

states, and various ego defenses and modes of adaptation. Milkman

and Frosch (1973), for example, have recently reported on a promising line of inquiry in applying to addicts a systematic study of

ego functions developed by Bellak and Hurvich. Their preliminary

findings show a relationship between an abuser’s characteristic

mode of adaptation and his/her preference for either amphetamines

or heroin.

We have said little up to this point specifically about character

pathology, and yet we know that our patients most often are referred to as “psychopaths, sociopaths, and antisocial characters.” I

believe these labels, so often used pejoratively, describe little that is

meaningful or accurate about addicts. Perhaps such descriptions

mostly indicate how little we understand character pathology. I

suspect that as we study such problems, we will gain a better appreciation of the relationship between various drive and affect states

and the ways in which such states contribute to or “drive” so-called

character pathology and related behavioral disorder such as narcotic

addiction. In my work with character problems, I am in agreement

with the proposition offered by Vaillant (1975) and Wishnie (1974),

that as control is gained over the behavior problems, underlying

psychopathology that was previously masked by the destructive

behavior emerges. Vaillant and Wishnie stress in particular the

underlying depression. My own experience not only emphasizes the

1

Zinberg has questioned seriously the role of preexisting psychopathology

as a major determinant of addiction. He has perceptively and persuasively proposed that regression in addicts is less a function of personality disturbance and

drug effect, but more, the result of being labeled as deviant, the loss of varied

contact with social and family relationships and the necessity to “cop.” Although his work is atvariance with the emphasis on developmental impairments

in this report, his point of view is not incompatible with what we have proposed. His study reminds us of the importance of “stimulus nutriment” from

the environment in maintaining autonomous ego functions (Zinberg 1975).
KHANTZIAN: EGO, SELF, AND OPIATE ADDICTION 107

underlying depression, but the presence as well of a range and

variety of mood disorders, phobic-anxious states and other neurotic,

characterologic, and psychotic symptoms. As we more precisely

identify such target symptoms and affect states, we will be in a

better position to decide on suitable forms and types of psychological and psychopharmacologic interventions.

SELF-CARE AND SELF-REGULATION2

In this section I would like to explore in a preliminary way an aspect of addiction which seems to have received little systematic

attention in the literature, related to a particular type of gap or

vulnerability in ego function of drug-dependent individuals. Namely,

I have been impressed with an apparent disregard that drug-dependent individuals show for a whole range of real or possible dangers

to their well-being, including their substance involvement. I believe

this type of self-disregard is associated with impairments of a

generic or global ego function that I have chose to designate as selfcare and self-regulation. I say “generic or global” because I suspect

such functions and their impairments are related to component ego

functions such as signal anxiety, reality testing, judgment, control,

and synthesis, and when impaired, to such defenses as denial, justification, projection, etc. As used here, the concept of self-care combines elements of all of these component functions and in this respect it is a complex function. But in other respects the functions

of self-care and regulation are so basic and elementary for survival

that they are sufficiently developed and present to be evident in

normal young children.

Before proceeding to elaborate on problems of self-care as an

ego function, I would like to stress what I am not referring to or

emphasizing in this discussion. Considerable references exist in the

literature to the obvious self-destructive nature of addictions. Often

in such cases reference is made to unconscious “death wishes.” In

other cases, referred to in the previous section, the apparent disregard and “not caring” is related to desperate attempts to ward off

painful feelings. In still other instances dangerous and violent behavior serves to counteract feelings of helplessness and dependency,

and as Wieder and Kaplan have correctly indicated, it is a mode that

is adopted against one’s sense of terror and vulnerability. In these

cases the actual and potential problems and danger for the person

2The author is indebted to Dr. John E. Mack for his assistance in the development of the germinal idea and concept of self-care as an ego function.
108 PSYCHODYNAMICS OF DRUG DEPENDENCE

are driven, over-determined, and defensive. These self-destructive

aspects of addiction have received considerable attention and will

not be the main focus of our attention.

For purposes here, I will stress how much of the addict’s selfdisregard is not so much consciously or unconsciously motivated,

but more a reflection of defects in self-care functions as a result of

failures to adopt and internalize these functions from the caring

parents in early and subsequent phases of development. The overdetermined and defensive forms of self-destructive behavior among

addicts do not adequately account for all the terribly dangerous and

destructive activity, to the point of death, that such people get into.

In such cases danger is not so much consciously or unconsciously

welcomed, or counterphobically denied, but rather is never anticipated, perceived and/or appreciated. These are problems that I consider to be related to self-care (ego) functions that are impaired,

deficient and/or absent in so many of the addicts we see. The

problems with self-care and regulation are apparent in their past

histories (pre-dating their addiction) by a high incidence of preventable medical and dental problems, accidents, fights and violent behavior, and delinquent/behavioral problems. Their impaired selfcare function is also evident in relation to their drug problems,

where despite obvious deterioration and imminent danger as a result

of their drug use, there is little evidence of fear, anxiety or realistic

assessment about their substance involvement. One might correctly

argue that in this latter instance the lack of self-care is secondary to

regression as a result of prolonged drug use. Although this is probably quite true, we have been impressed with the presence and persistence of these described tendencies in such individuals both prior

to becoming addicted, and subsequent to becoming drug free and

stabilized. In fact much of our therapeutic work beyond detoxification involves the work of helping our patients to identify these

impairments around self-care, and to help them learn to incorporate these functions for the first time in their daily living and

behavior.

In contrast to the compulsive aspects of drug use where drugs

come into a person’s life to serve purposes of defense and adaptation, some of the more malignant aspects of drug addiction that we

are stressing here are related to the impulsive, maladaptive side of

the problem. That is, the addiction to drugs and the associated involvements and activities, that are often equally as dangerous, represent a failure in the person’s ego to properly assess, warn, and protect the individual against the dangers in a whole variety of settings

and situations, not the least of which is the setting associated with

addictions.
KHANTZIAN: EGO, SELF, AND OPIATE ADDICTION 109

Some examples taken from a women’s correctional institution

where most of the individuals have been drug ‘free and relatively

stable for some time are presented for purposes of illustration.3

Some of the most telling examples are evident in relation

to health issues: failure to clean needles that are shared is

common; gross dietary indiscretions such as the diabetic

failing to adhere to a proper diet or an inmate’s buying the

most spicy foods despite a chronic ulcer; failures in the

sexual sphere to take precautions against pregnancy or to

worry about the possibility of venereal disease, or to obtain

regular gynecologic examinations.

Then there are people who “just happen to be in the

wrong place at the wrong time.” For example, one inmate

went shopping with her boyfriend and was arrested for

shoplifting after the boyfriend asked her to hold a bag containing a suit he had shoplifted. Another woman landed in

jail because she believed her male friend, who told her that

she was just “live parking” the car while he went to the

bank, when in fact she was driving the getaway car.

Another inmate went for a walk with a girlfriend whom

she knew was planning to shoplift. She was caught and

arrested for shoplifting and protested that she was “only

going along for the fresh air” and couldn’t figure out why

she was charged.

In our own drug program we have been impressed with the many

11th hour lapses, oversights, mistakes and crises in which patients

find themselves, that undermine employment opportunities and

treatment and education plans that the patient and the program

staff have worked hard to realize.

In all of the examples it is not uncommon to hear such people

reply, “I didn’t think about it,” when questioned as to how they

could leave themselves so vulnerable. Usually, our dynamic formulations about such behavior stress such consideration as regression,

unconscious wishes, conflict, denial and repetition compulsion. I

believe these formulations do a disservice to understanding the

problems of these individuals. These explanations fail to consider at

face value that the apparent oblivion in their “not thinking” statements accurately reflects the locus of the problem. To quote from

3The author is indebted to Dr. Catherine Treece for these vignettes and

case examples.
110 PSYCHODYNAMICS OF DRUG DEPENDENCE

another report, we summarized the problem as follows: “Although

much of this behavior is dynamically motivated and defensive in

nature, as well as symptomatic of regression, in other respect these

individuals’ apparent self-disregard (“thoughtlessness”), delinquency, failure to comply with assigned treatment plans, missed

appointments, tardiness, etc., reflect a particular kind of absence

and impairment in ego function, that predisposes people to mishaps

and mistakes. These are functions which when better established,

either automatically guide most of us away from trouble, or once

in trouble, these and similar ego functions are mobilized, again

fairly automatically, to direct us out of trouble” (Khantzian and

Kates 1976).

In my opinion, it is specifically around this kind of impairment

that we need to structure treatment programs. We must provide

measures that actively and directly both respond to the overdetermined need to fend off help, and deal with the tendency of these

individuals to be insufficiently anxious, concerned, and responsive

about so many aspects of their life, but especially, about self-care

measures.

As indicated previously, our description of self-care and regulation as an ego function probably consists of elements, components,

and processes related to other ego functions. In our estimation the

adoption of a construct such as self-care as a possible unique ego

function has particular utility and explanatory value in trying to

understand behavioral problems in general and the maladaptive

aspects of addiction in particular. This function is related to signal

anxiety, and along lines developed by Krystal and Raskin (1970),

serves to guide us in relation to external dangers, threats and

involvements. Krystal and Raskin stress the role of signal anxiety in

relation to internal states and how in its absence the individual

tends to be overcome by overwhelming affects. With self-care

functions, our emphasis is on the person’s external world and his

surroundings; when self-care functions are inadequate, the individual fails to perceive or judge realistically various dangers and

threats. This function and its impairments are also related to ego

functions involving “synthesis” and bear many similarities to this

function as explained and applied by Chein et al. (1964) to the ego

impairment of narcotic addicts. However, we believe this emphasis

on self-care as an ego function, with the emphasis on external

dangers and threats, is warranted because both the concepts of signal anxiety and synthetic functions stress intrapsychic processes

and mechanisms, and fail to stress sufficiently and take into

account the individual’s adaptation to reality and the world around

him.
KHANTZIAN: EGO, SELF, AND OPIATE ADDICTION 111

THE SELF AND NARCISSISTIC DEFENSE

In this section I would like to focus briefly on some distinctive

character features and traits common among addicts. In the previous two sections of this paper we have stressed ego mechanisms that

serve a function in personality organization and adaptation. In this

section, attitudes about the self and others, and the ways in which

such attitudes are incorporated into character traits/styles will be

stressed. Kohut (1971) and Kemberg (1975) have recently elaborated on how disturbances in early child rearing, especially around

nurturance and dependency needs, lead to narcissistic disturbances

in adult life. (Narcissism refers to new scientific work on the self,

including the vicissitudes of its development and its ultimate deficiencies or intactness—ed.) Although both Kohut and Kernberg

have indicated that narcissistic pathology predisposes certain individuals to addiction, neither has systematically explored the relationship between narcissistic disturbances and addiction. Wurmser

has made a major contribution by expanding on this work and carefully reviewing the narcissistic basis for defects in affect defense,

faulty ego ideal formation, pathological dependency and enormous

problems that addicts have with rage, shame, hurt and loneliness.

Wurmser’s work (1974) has placed emphasis on narcissistic decompensation and the part that drugs play in allaying and countering painful affect states and narcissistic disturbances that result

from an overwhelming crisis in the individual’s life. In my own

work, I have recently become interested in trying to identify and

understand better some of the unique and characteristic traits of

compensated addicts that are related to narcissistic processes and

disturbances. More specifically, in psychotherapeutic work with

stabilized addicts (i.e., post-detoxified or on drug maintenance) I

have been interested in exploring some of the special qualities and

problems addicts display in obtaining satisfactions of their needs.

Despite their totally and/or relatively drug-free state, extreme and

often alternating patterns of reactions in relation to their need

satisfactions persist. In the therapeutic relationship, the most commonly observed feature is the extent to which such patients go to

be compliant, cooperative, and most of all, what little demand the

patient places on the therapist for very long periods of time. Most

often this takes such forms as passivity, indifference, solicitousness,

disavowal, and self-sufficiency.

Occasionally, such patients lapse and display another side to

themselves, for example, a most inappropriate intrusiveness into

the life and activities of the therapist, and an assumption that their

curiosity will or ought to be satisfied; on other occasions a request
112 PSYCHODYNAMICS OF DRUG DEPENDENCE

will be made that superficially sounds innocent and undemanding,

but actually reveals an enormous sense of entitlement and total lack

of appreciation about the magnitude and sensitivity of their request.

One such patient in the course of his employment discovered he

needed some confidential information on a person who was affiliated with an institution in which the therapist worked. In a matterof-fact way he asked the therapist to obtain this information for

him. He seemed totally surprised and hurt when he was tactfully

informed that his request was unreasonable.

Most of these same patterns carry over to their everyday life. In

reviewing these patterns with such patients one discovers that many

of their complaints of boredom, depression and dissatisfaction are

related to these same rigidly maintained patterns of self-denial

observable in their small demands in therapy. At other times one

hears accounts of massive explosions of anger and frustration as a

result of chancing some wish or want and then experiencing massive

disappointment.

Kernberg (1975) has stressed mechanisms of splitting and primitive dissociation in narcissistic disturbances, where for example,

seemingly opposite ego attitudes of shyness and arrogance may

coexist. Kohut has emphasized massive repression and disavowal

of needs to describe how narcissistic personalities attempt to

defend against their passive wishes and wants. These are not at all

uncommon characteristics and modes of defense in narcotic addicts

with whom I have worked; and I believe these characteristics

account for so much of the unevenness in function, and unpredictability and contradiction in attitudes in such patients. In one

patient the following characteristics have been persistently and

simultaneously evident:

Solicitous-When he first came for treatment, he went

out of his way to be extremely chatty and friendly with all

the secretaries in a nearby administrative area. He has

always gone out of his way to light people’s cigarettes, including that of his therapist. When the therapist has been

late, he has never complained, and more often goes out of

his way to dismiss any resulting inconvenience to himself. In

his job he has the reputation of being most kind and supportive.

Ruthless-In business negotiations he is not adverse to

subterfuge and intimidation to exact an outcome to his

liking.

Violent, Sadistic and Explosive-While addicted to heroin

he was involved in a number of brawls and fights and broke

his hand on one occasion and sustained a number of other
KHANTZIAN: EGO, SELF, AND OPIATE ADDICTION 113

injuries and lacerations in other fights. On more than one

occasion he brutally beat a pet cat to death because the cat

scratched, disobeyed, or frustrated him, At work his executive director avoided him because of menacing, explosive

confrontations.

Passive-Whatever dates or social contacts he had were

usually at the initiative of friends and family. Despite his

passivity, and probably because he is likeable, women at

work ask him for dates and do favors for him. He spends

many weekends alone watching T.V.

Active/Restless-He went out of his way at work to

assume risky security responsibilities and functions. He has

always been attracted to leisure activities and sports that

are the most active, exciting, and dangerous. His hobbies

barely sublimate his aggression. Although his drug involvement has often placed him on the other side of the law, he

has always been intrigued with law enforcement activities

and enjoyed his contact with law enforcement personnel.

He recently took up martial arts.

Disavowal-He insists that he must be tough in his work

or he will be considered a “patsy and soft.” He has insisted

that he can handle his loneliness and doesn’t need companionship. Despite this he will often cruise in his car seeking a

pickup. Recently and after much therapeutic work he now

admits that he is worried less about rejection in asking for

dates, but feels awkward and embarrassed to reveal his need

and interest in companionship.

The need for satisfactions, shown in the patient described, is

countered by a need to maintain psychological equilibrium and

homeostasis. Such patients are in constant fear that their precarious

equilibrium will be disrupted. Defenses that are commonly employed to maintain such an equilibrium include denial and disavowal. Passive longings and wishes are frequently defended against

by activity and the defensive assumption of aggressive attitudes. To

indulge wishes and wants is felt to be hazardous because one runs

the risk of disappointment, frustration, rage, and narcissistic decompensation. Defenses are employed in the service of containing a

whole range of longings and aspirations, but particularly those

related to dependency and nurturance needs. It is because of massive repression of these needs that such individuals feel cut off,

hollow and empty.

We suspect that addicts’ inability to acknowledge and pursue

actively their needs to be admired, and to love and be loved, leave

them vulnerable to reversion to narcotic addiction on at least two
114 PSYCHODYNAMICS OF DRUG DEPENDENCE

counts. First of all, in failing to find suitable outlets for their needs,

they fail to build up gradually a network of relationships, activities

and involvements that act as buffers against boredom, depression,

and narcissistic withdrawal; this latter triumvirate of affects acts

powerfully to compel such individuals to use opiates. Furthermore,

in failing to practice at expressing and chancing their wants and

needs, they are then subject to sporadic, uneven breakthroughs of

their impulses and wishes in unpredictable and inappropriate ways

that are often doomed to frustration and failure. The resulting rage

and anger that grows out of such disappointment also compels a

reversion to opiates.

TREATMENT IMPLICATIONS

We believe that effective treatment of narcotic addicts rests on

more precisely identifying the underlying psychopathology and

character disturbance. To do this requires the establishment of control over the addiction and the destructive activity and behavior

often associated with it. However, this is understandably no easy

task. The addict trusts his solutions more than ours. We also know

that the use of drugs has played a most important part in regulating

and controlling the addict’s otherwise overwhelming anxiety, depression and rage. The challenge of initial treatment interventions

is to provide acceptable provisions and substitutes for the drugs in

order to create the structure and time that make understanding

and management of the addict’s problems possible. Briefly, our

main allies for intervention and treatment remain the traditional

institutions (courts, prisons, and hospitals), drug substitution (e.g.,

methadone maintenance, other psychoactive drugs) and human

relationships. The specific ways in which we employ these interventions will be touched upon briefly in this discussion.

In many instances, institutional treatment will continue to be

imposed, and in certain cases, required. Such options continue to be

distasteful to most of us, but often necessary. As time goes on we

may devise institutions that will avoid the extremes of prisons

where there is too little understanding, and hospitals where there is

perhaps too much understanding but insufficient controls. The balance of controls and understanding is essential for the management

and treatment of behavioral problems.

Although we, and others, have advanced specific hypotheses that

propose a psychological and physiologic basis for the clinical effectiveness of methadone maintenance, I suspect that one of the main
KHANTZIAN: EGO, SELF, AND OPIATE ADDICTION 115

benefits of methadone maintenance is the general control and internal chemical support the individual derives which then makes other

human interventions possible. Methadone and other psychotropic

drugs similarly have a generally “prosthetic” value and act as a

benign chemical substitute for those used by our addicts.

As the available range of interventions helps to establish control

over the malignant aspects of drug use, in subsequent phases of

treatment we will be in a better position to identify and grapple

with the specific impairments, vulnerabilities and characteristics of

narcotic addicts. As we have already indicated, drug use and its

attendant activities have substituted for defenses, relationships and

other satisfactions. As this process is reversed with increasing control, the usual result is the emergence of underlying psychopathology and characterologic problems.

Some psychotherapeutic implications for these problems have

already been hinted at. The necessity for consistency, empathy,

activity and availability is apparent. Readiness to put into words the

addict’s feelings that he can hardly recognize or identify for himself, or others, is essential. Firm but non-punitive confrontation of

violent and unacceptable behavior is also often required. The therapist must also be active in pointing out the patient’s inability or

disinclination to perceive danger and risk in his daily living.

The fragile to non-existent self-esteem in addicts must be appreciated continuously. Massive confrontations about their problems

with violence and rage should be avoided. Similarly, passive longings and dependency problems should not be overexposed; defenses that serve to disguise such problems should be dealt with

gingerly and respectfully. However, one should not ignore the destructive consequences and/or withdrawal when such defenses are

extreme and exaggerated. I have found it useful to approach these

problems gradually by identifying the difficulties around the inability of such patients to gain “sufficient satisfaction” out of life. This

is done by repeatedly but tactfully identifying, whenever it comes

up, the patient’s tendencies to pursue extremes of indulgence or

self-denial in relation to his wishes, relationships and activities. In

the therapeutic relationship, extremes’ of aloofness or exaggerated

friendliness are avoided by the therapist; questions are answered;

sharing of personal experience and requests for practical assistance

around daily living problems are again dealt with by avoiding

extremes of withholding or, giving. Generally, attempts are made

to gradually help our patients overcome their exaggerated selfsufficiency and to see that they can overcome their fears and mistrust about involving themselves, and that the world can provide

reasonable degrees of satisfaction.
116 PSYCHODYNAMICS OF DRUG DEPENDENCE

Finally, some brief consideration about the use of psychoactive

drugs seems pertinent. Clearly, addicts to some extent have known

what is good for them. Had they not medicated themselves, many

would not have survived or lived as well or as long as they did. It is

surprising then to see how often psychotropic drugs are withheld

and/or not considered in so many treatment programs. I believe

that it is heroic and unrealistic to believe that we can reverse or

resolve the enormous psychological damage and impairment in

addicts through our psychotherapeutic interventions alone. We

should be ready to consider flexibly the use of psychotropic drugs

as an adjunct to psychotherapy, or as the primary therapy, depending on the assessment of the degree and nature of the addict’s

impairment, and a precise identification of target symptoms and

affect states. Klein (1975) has recently reviewed psychopharmacological approaches to borderline states and strongly urges that we

work to identify target symptoms better, with a particular emphasis

on affect states. He also stresses the efficacy of matching specific

types of antidepressants (e.g., MAO inhibitors vs. tricyclics) and

phenothiazines to target symptoms and affect states, and the use of

lithium for stabilizing affect swings and behavior. These are promising findings that are applicable to the understanding and treatment

of narcotic addiction and warrant further study.

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Klein, D.F. Psychopharmacology and the borderline patient. Borderline States

in Psychiatry. New York: Grune & Stratton, 1975.

Kohut, H. The Analysis of the Self. New York: Int. Univ. Press, 1971.

Krystal, H., and Raskin, H.A. Drug Dependence. Aspects of Ego Functions.

Detroit: Wayne State Univ. Press, 1970.

Mahler, M.S. On Human Symbiosis and the Viscissitudes of Individuation. New

York: Int. Univ. Press, 1968.

Meissner, W.W., Mack, J.E., and Semrad, E.V. Classical psychoanalysis. In:

Comprehensive Textbook of Psychiatry. Freedman, A., Kaplan, H.I., and

Sadock, B.J., eds. Baltimore: Williams & Wilkins, 1975.

Milkman, H., and Frosch, W.A. On the preferential abuse of heroin and amphetamine. J Nerv Ment Dis, 156:242-248, 1973.

Rado, S. The psychoanalysis of pharmacothymia. Psychoanal Q, 2:1-23, 1933.

Narcotic bondage. A general theory of the dependence on narcotic

drugs. Am J Psychiatry, 114:165-170, 1957.

Savit, R.A. Psychoanalytic studies on addiction: Ego structure in narcotic

addiction. Psychoanal Q, 32:43-57, 1954.

Vaillant, G.E. Sociopathy as a human process. Arch Gen Psychiatry, 32:178-

183, 1975.

Wieder, H., and Kaplan, E.H. Drug use in adolescents: psychodynamic meaning

and pharmacogenic effect. Psychoanol Study Child, 24:399-431, 1969.

Wikler, A.A., and Rasor, R.W. Psychiatric aspects of drug addiction. Am J Med,

14:566-570, 1953.

Winnicott, D.W. Transitional objects and transitional phenomena. Int J Psychoanal, 34:89-97, 1953.

Wishnie, H. Opioid addiction: A masked depression. Masked Depression.

S. Lesse, ed. New York: J. Aronson, Inc., 1974.

Wurmser, L. Psychoanalytic considerations of the etiology of compulsive drug

use. J Am Psychoanal Assoc, 22:820-843, 1974.

Zinberg, N.E. Addiction and ego function. Psychoanal Study Child, 30:567-

588, (T), 1975.
CHAPTER 8

Transference Phenomena in the

Treatment of Addictive Illness:

Love and Hate in Methadone

Maintenance

Virginia Davidson, M.D.

INTRODUCTION

Wilfred Bion observed that “society, like the individual, may not

want to deal with its stresses by psychological means until driven to

do so by a realization that at least some of its distresses are psychological in origin” (Bion 1959). After more than a decade of experience in methadone maintenance, there is now widespread acknowledgment-even if it is belated, often grudging, and sometimes

obscure-that attempts to treat heroin addiction by chemical means

alone have failed. This admission of failure has crept stealthily into

the literature, seemingly unnoticed at any given time because of the

lack of emphasis on its presence. Terms such as “ancillary services,”

“social, personal, or vocational rehabilitation,” and “supportive

counseling” camouflage the fact that some meaningful psychological intervention has to take place in the treatment of addicted

patients, or they will relapse to heroin use. Each time we read these

phrases, we assume we know what they mean. They are as expectable by now, and are about as brief and meaningful as the complimentary close at the end of a business letter. Recent, typical examples from the March 1976 Archives of General Psychiatry include

this statement from one author’s summary about the effectiveness

of the narcotic antagonists (Meyer et al. 1976):

Blocking drugs may be very usefully applied as adjuncts

(italics mine) to psychologic intervention.

118
DAVIDSON: TRANSFERENCE PHENOMENA 119

From another article (Goldstein 1976) in the same journal we learn

that:

Alternative satisfactions have to be developed to substitute

for those previously obtained from heroin. Experiences that

are better and more satisfying than heroin use have to be

built into a new behavioral repertoire. Self-image has to be

improved, a new sense of worth has to be developed.

The author goes on to say that without this accomplishment, relapse

to heroin use is virtually certain. Who with experience in treating

addicts would disagree with such a sensible observation? Yet there

is little in the literature of the treatment of the addictions which

indicates that we understand what such claims imply about the

necessity for accomplishing such massive personality change in

addicted patients.

If the allegations are taken seriously that psychologic intervention will be necessary in conjunction with whatever chemical

remedy is offered to treat addictive illness, it is curious that no coherent body of literature has developed that addresses the problems

of psychologic treatment even after there is agreement that it is

necessary.

Rather, the introduction of each new chemical is associated with

an eagerness to discard the previous experience gained concerning

the need for psychologic intervention, and hope emerges for a brief

time that the new drug alone will produce a cure. This cycle has

operated through the introduction of methadone, long-acting

methadone, and each one of the narcotic antagonists, by turns. The

wish to locate the cure for addictive illness outside the patient’s

psyche is obviously very strong in the persons who have been engaged in drug abuse research and treatment over the past 10 years.

It probably exists in a stronger form only in the addicted patient

him- or herself, where it is called “denial.” Yet it is interesting to

note that the same process exists in patients and researchers alike,

though with perhaps varying degrees of intensity.

BACKGROUND

In this paper I shall describe certain recurring patterns of behavior which I observed in methadone maintenance patients during

a 34-month period I worked in the setting of a methadone maintenance clinic. I shall relate these patterns to the descriptions in the

psychoanalytic literature of ego defense mechanisms, and draw

certain parallels between the behavior I observed in the clinic setting with the descriptions of transference phenomena which have
120 PSYCHODYNAMICS OF DRUG DEPENDENCE

been observed in the psychoanalysis of patients with so-called

borderline personality organization (Kemberg 1975). Other writers,

notably Khantzian, Mack, and Schatzberg (1974) and Vaillant

(1975) have called attention to the primitive nature of the defenses

in addicted patients. The defenses which Vaillant refers to as

“immature”—splitting, denial, and projective identificationcorrespond to those which characterize patients with borderline

personality organization, best described by Otto Kemberg (1975).

Khantzian, in his study, notes an absence of neurotic defenses in his

patients, but does not go on to describe the existence of more

archaic patterns. Leon Wurmser (1974) has added much to the

understanding of compulsive drug use’ by relating it to “narcissistic

crises” in the lives of the individual drug abusers. Wurmser states

that he has never seen a compulsive drug abuser who was not emotionally deeply disturbed, and he links this disturbance to the

borderline type of psychopathology. In spite of observations such

as these by persons who have had considerable experience in treating addicted patients in individual psychotherapy, most of the

psychological treatment of addicts will be left to those persons in

the treatment hierarchy who have the least knowledge and experience in psychotherapy. There are no serious attempts to gain-for

addicts-access to the best forms of psychotherapy available, partly

because of the process that involves denying that addictive illness

has psychological origins, but also because of the extremely trying

nature of therapy with borderline patients (Leibovich 1975; Pines

1975), even if they are not addicted to heroin.

TRANSFERENCE PHENOMENA AND

COUNTERTRANSFERENCE BEHAVIOR

Transference is a term which implies that the patient’s behavior

at a given moment in treatment is determined more by his very

early experiences with significant others than by the reality stimulus of the present setting.

I use the term transference phenomena to refer to observable

patterns of behavior in patients’ transactions with clinic staff members and the clinic itself, as well as in their relationships with individual therapists. Whenever there are rapid shifts in the way patients

perceive others, whenever strong affective states such as love or

hatred are predominant (and especially when there is rapid alternation between the two), and whenever there is a powerful projection

of hostile, aggressive impulses from the patient to someone else, it

is safe to say that transference phenomena are present. These re-
DAVIDSON: TRANSFERENCE PHENOMENA 121

sponses I have just described are not perceived by the patient as

being unusual or strange, in fact they are natural for him or her, and

characterize the styles of relating to others that he/she has developed from early life.

Counter-transference, as used in this paper, will refer to the

totality of the therapist’s response to the patient. It includes reality

factors such as the setting and the working alliance with the patient,

plus the internal response of the therapist to the patient.

CHARACTERISTIC PATTERNS OF BEHAVIOR IN THE

CLINIC AND RELATED MANAGEMENT PROBLEMS

The behavior of methadone patients in the clinic setting is remarkable in several respects, when compared with the behavior of

other groups of psychiatric patients whose treatment utilizes the

outpatient clinic format. I shall focus on three major observable

differences in the clinic behavior of methadone patients, and comment on the kinds of difficulties each one presents for staff management in the outpatient methadone maintenance clinic. I believe that

these patterns of behavior are roughly equivalent to the ego defense

mechanisms of splitting, projective identification, and denial, which

have been described in the psychoanalytic literature dealing with

the treatment of borderline patients (Kemberg 1975), even though

the behavior described is occurring in the context of an outpatient

clinic.

1. Analogous to splitting are manifestations in the clinic setting

of extreme affects, which appear to be inappropriate to the reality

stimulus of the moment. These affective states are usually characterized by extreme rage; for example, murderous hatred can be

expressed by a patient toward a dispensing nurse who does not

ready the medication as soon as the patient expects it. This expression of rage is limited to the situation in which it emerged-the

patient does not carry the feeling over to everyone else he/she encounters. Feelings of contrition and remorse are likely to follow

closely the expression of hatred and rage. What is familiar to

workers in methadone is the rapidity with which patients can oscillate between extreme states of feeling. The patient has diminished

capacity to modulate feelings, so must swing back and forth between

strong positive and strong negative affects.

Problems for staff in relating to this aspect of the addicted

patient’s personality are enormous. Expression of strong hostility,

anger, and blamefulness in patients arouses equally powerful emo-
122 PSYCHODYNAMICS OF DRUG DEPENDENCE

tions in staff, whose most common response is to retaliate--overtly

or covertly-against the patient. In physicians, this is most commonly expressed through the dosage of methadone, since this is the

powerful medium through which most patient contacts occur. All

of us know patients who manage to alienate the staff one by one,

then find themselves removed from the program for violations of

one sort or another. The staff is usually not aware of this process,

and will deny-if asked-feeling hostility and suppressed rage

toward the patient. In a well-run program this process of retaliation

against the patient can be minimized by enlightened supervision,

ideally by someone outside the treatment system.

Related to retaliation as a means of coping with the patient’s

tendency to experience strong emotions separately and intensely

(splitting), is pairing. Patients “select” a staff member with whom

they establish a dependent, demanding, and clinging relationship.

Few negative emotions are channeled into this relationship, but

rather are expressed in strong dislikes for and refusals to deal with

other staff. The “chosen” staff person becomes the patient’s advocate in all matters relating to progress and performance, and may at

times jealously protect the patient from having contact with other

staff. While patient-staff pairing is less destructive than retaliation,

in that it allows some patients to remain in treatment through thick

and thin, it cannot be therapeutic for the patient unless it carries

some generalizability to other relationships. As long as the therapist

is obtaining gratification from the “specialness” of the relationship,

this is not likely to occur.

2. Analogous to projective identification is the expectation on

the part of patients that they will be unfairly dealt with by treatment personnel, and an associated tendency to perceive the external environment as hostile and threatening, regardless of what the

actual circumstances are. Because of the fact that addicts live

dangerous lives in their search for drugs, and because they are frequently incarcerated or are being implicated in criminal activities,

we assume it is reasonable for them to behave in a suspicious,

guarded, and untrusting manner when they come to treatment.

While this kind of explanation might possibly account for the

addict’s initial problems in relating to the staff, it cannot begin to

account for the persistent incapacities in forming trusting relationships that exist for years after the patient has begun treatment.

For any staff, the task of providing the qualities that are necessary for a therapeutic alliance to be established with the patient is

difficult when the patient’s problems are manifest in qualities that

appear to make this primary task impossible. Staff members, to be

effective, must maintain the capacity to be empathic toward the
DAVIDSON: TRANSFERENCE PHENOMENA 123

patient; the patient, however, behaves in such a way toward “helping” people that this empathic quality in staff is always undermined and jeopardized. All therapists must maintain a sense of their

own worth and value; they must have self-esteem and a sense that

the work they do with patients “matters.” Yet when the patient’s

style of relating involves projecting onto others the intensely aggressive, hostile, and negative impulses felt inside, the other person (in

this case, the therapist) receives constant messages that he/she is

being aggressive, hostile, and unsympathetic toward the patient. In

my experience, most methadone patients are not capable of distinguishing the origin of these hostile impulses except after years of

exposure to a person who can remain relatively neutral in the face

of these sorts of accusations.

With therapeutic problems of this magnitude, not to become

locked into an equally hostile countertransference relationship is a

monumental task for the best-trained and most talented of therapists; for the untrained, unskilled, and uninitiated, it is virtually

impossible.

3. Denial of entire segments of reality, especially involving behavior concerning drug usage is typical; related forms of denial are

evident in the need patients demonstrate to appear impervious to

the impact methadone maintenance has on their lives. Patients commonly express the belief that they are in control of their drug usage

-they maintain that they will be able to withdraw from methadone

at a future time of their own choosing, even after previous attempts

have resulted in quick relapse to heroin. Years of compulsive drug

use have not altered the psychic reality of many patients-namely,

disbelief in the reality of the psychologic component of their addictive illness. Denial of feelings of anxiety and depression in addicted

patients has been discussed by other writers (Vaillant 1975), as well

as the return of these feelings during attempted withdrawal from

methadone and the necessity for psychological support during withdrawal (Chappel et al. 1973; Lowinson and Langrod 1973). Denial,

in the psychological sense, is most often confused by staff with conscious lying and manipulation. While addicted patients certainly

have in common with other patients the habits of lying and manipulation, it is impressive to what extent the latter explanations are

used by staff members to account for patients’ behavior.

The gruff, loud, and complaining behavior that patients exhibit

toward appointments often covers up the desperate fear these

patients have about emotional contact with another person. Their

apparent superficial involvement in counseling is often interpreted

by staff as “low motivation.” Grumbling about having to keep

appointments, complaints about the time lost in the clinic, and
124 PSYCHODYNAMICS OF DRUG DEPENDENCE

especially assertions that the counseling relationship is a waste of

time, may mask the patient’s terror of involvement.

Many times I have had the experience of hearing vituperative

protests from patients that keeping their appointment with me

would cause them to be fired from the job; that they simply could

not afford the time to discuss their medication, and so on. Yet

these same patients, once in the office, shed their belligerence like

an unwanted skin, and want to discuss more than their medication.

So what masquerades as a devil-may-care attitude toward the clinic

frequently represents massive denial of the importance of the clinic

in the patient’s life. Sometimes only during withdrawal from methadone does this attachment to the clinic enter the patient’s awareness.

CONCLUSION

By describing typical patterns of behavior that can be observed in

methadone maintenance patients in the outpatient clinic setting, I

have attempted to demonstrate that this behavior is markedly different from that observed in other groups of psychiatric patients

who are treated in outpatient clinics. Much of the “difficult” behavior is often seen as part of a constellation of undesirable social

characteristics attributed to addicted patients. Staff may try to

eradicate this behavior (usually through elaboration and enforcement of clinic rules) with the associated hope that the patient will

become more compliant, and then amenable to therapy. This is

somewhat akin to stating that if the patient did not have psychological problems he/she would be easier to treat.

I am suggesting that the behavior we see in the patient is the

manifestation of his/her problems in living, and not an artifact of

either the clinic setting or of the addicted patient’s sociocultural

background. This behavior makes sense, so to speak, if it is related

to the ego defense mechanisms which have been delineated in the

psychoanalytic study of borderline patients. The problems which

this behavior presents for the outpatient psychotherapy of addicted

patients are considerable, as I have attempted to show, and are

similar to the problems encountered whenever the treatment of any

borderline patient is undertaken. Understanding why (and when)

patients establish negative transferences can lead to effective management, and to the prevention of transference psychoses, which

are not infrequent in this population of patients. It is crucial to protect and nurture the positive transference relationships that develop;

for many patients it is easier first to establish a positive bond with

the clinic than with a counselor. Whenever clinics are structured in
DAVIDSON: TRANSFERENCE PHENOMENA 125

such a way that this is an unreasonable expectation, treatment

prospects remain glum.

REFERENCES

Bion, W. Experiences in Groups. New York: Basic Books, 1959. p. 22.

Chappel, J., Skolnick. V., and Senay, E. Techniques of withdrawal from methadone and their outcome over six months to two years. Proceedings of the

5th National Conference on Methadone Treatment, Washington, D.C.,

1973. pp. 482-469.

Goldstein, A. Heroin addiction. Arc Gen Psychiatry, 33(3):353-358, 1976.

Jackman, J. A hypothesis concerning the difficulty of withdrawal from maintenance of methadone. Proceedings of the 5th National Conference on

Methadone Treatment, Washington, D.C., 1973. pp. 471-475.

Kernberg, 0. Borderline Conditions and Pathological Narcissism. New York:

Jason Aronson, 1975.

Khantzian, E., Mack, J., and Schatzberg, A. Heroin use as an attempt to cope:

Clinical observations. Am J Psychiatry, 131(2):160-164, 1974.

Leibovich, M. An aspect of the psychotherapy of borderline personalities.

Psychother Psychosom, 25:53-57, 1975.

Lowinson, J., and Langrod, J. Detoxification of long-term methadone patients.

Proceedings of the 5th National Conference on Methadone Treatment,

Washington, D.C., 1973. pp. 256-261.

Meyer, R., Mirin, S., Altman, J., and McNamee, B. A behavioral paradigm for

the evaluation of narcotic antagonists. Arch Gen Psychiatry, 33:371-377,

1976.

Pines, M. Borderline personality organization, Psychother Psychosom. 25:58-

62, 1975.

Vaillant, G. Sociopathy as a human process. Arch Gen Psychiatry, 32:178-183,

1975.

Wurmser, L. Psychoanalytic considerations of the etiology of compulsive drug

use. J Am Psychoanal Assoc. 22:4, 820-843, 1974.
CHAPTER 9

Implications of Psychodynamics for

Therapy in Heroin Use: A Borderline

Case

Eugene H. Kaplan, M.D.

Psychoanalytic formulations began with the psychoneuroses.

Freud subsequently studied more severe disturbances as well,

developing his theories of narcissism and the psychoses (Freud

1957a, 1957b). The scope has expanded to embrace the whole

gamut of mental conditions, with the ultimate goal to make psychoanalysis a general psychology (Loewenstein et al. 1966). At the

same time, the progressive refinements in theoretical conceptualization have permitted increasing precision in defining psychopathology in terms of id, ego and superego functions and malfunctions.

The early psychoanalytic literature emphasized the instinctual

drive component of drug abuse (Yorke 1970). Interdependent

advances in clinical observation and theory have equipped us better

to study heroin users. Pfeiffer has reviewed the evolution of the

concept of the borderline states (1975). In 1942, Deutsch described

“as-if” personalities. Psychoanalytic treatment showed the common

thread of an impoverished emotionality different from the schizophrenic, with widely different symptom pictures (1942). Hoch and

Polatin (1949) reported on a group of patients who showed both

neurotic and psychotic features, but were classifiable as neither. In

Schmideberg’s view, this group bordered not only on neurosis and

psychosis, but on psychopathy and normality as well (1959).

Grinker’s research team found multiple, shifting psychological defense mechanisms in hospitalized borderline patients (1968).

Grinker considered this shifting combination of neurotic, psychotic,

psychopathic and normal defense mechanisms to typify borderline

126
KAPLAN: IMPLICATIONS FOR THERAPY 127

patients. Using the theoretical framework of psychoanalytic ego

psychology and following Knight’s suggestions, he assessed ego

functions systematically (1953). Grinker concluded that the borderline syndrome is characterized by the arrested development of ego

functions.

Summarizing some salient features of the borderline syndrome

will make it clear why many heroin users are classifiable in this diagnostic rubric (Pavenstedt 1967; Minuchin et al. 1967):

(1) Intractable mistrust and suspiciousness, with a predisposition for transient paranoid psychotic episodes.

(2) Stunted cognitive capacity, fixated on concrete thinking, with relatively little abstract conceptualization. This

leads to an inability to profit from past experience, to look

ahead to the future.

(3) Intense self-centeredness and preoccupation with needsatisfaction, with obliviousness to the rights, needs and desires of others. These traits seriously interfere with personal

relationships, which tend to be brief and manipulative, or

markedly dependent and ambivalent. The other person is

viewed as a supplier of needs, an obstruction to need-gratification, or a danger.

(4) Fluidity and insufficient demarcation of self-boundaries.

The intense dependent relationships (which might appear to

contradict the feature of egocentricity), often involve such

fluid self-boundaries. The other person is viewed not as a

separate and distinct entity, but as part of the self. This can

lead to catastrophic separation reactions.

(5) Self-esteem is highly volatile, and exquisitely dependent

on external sources rather than inner resources.

(6) Self-control is poor and dependent on cues and signals

from external sources. Control emanates from others rather

than from internalized norms and values.

Points 5 and 6 indicate that, despite the self-centeredness, overall

mental functioning is characterized by disequilibrium resulting from

an inability to rely on oneself.

(7) Emotions tend to be strong and primitive, “all-ornothing,” without nuances and refinements, and heavily

laden with hostility and aggression.

(8) Many of the above contribute to the proclivity to impulsive action.

The number of chronic heroin users who have been psychoanalyzed is very small. To these data, we may add the clinical findings of psychoanalytically trained observers working with such

patients in other settings. While statistical studies of the mass treat-
128 PSYCHODYNAMICS OF DRUG DEPENDENCE

ment programs deserve careful scrutiny, Stoller argues compellingly

for the heuristic usefulness of the individual case history:

. . . the intensively studied single case has given way to the

more rapidly observed many. There is certainly good reason

for this: extravagant conclusions have frequently been

drawn from a single case; at times these conclusions have

not even followed from the data collected. Moreover, it has

often been impossible to be sure what were actually data

and what was conjecture. These difficulties have led to the

present emphasis on controlled studies with adequate samples. Not only does the researcher thus conform more to the

standards of science but he also renders his activity less

painful . . . he reduces his involvement with his subjects’

distress . . . and he avoids the sense of uncertainty that besets the clinician in his one-to-one relationship with his

patient.

Yet, although statistical techniques may enable us to

corroborate or deny a hypothesis, they do not produce one.

On the other hand, as Freud’s work shows, the extended

case study is an inexhaustible source of ideas. Unhappily,

those of us who are clinicians, especially psychoanalysts,

seem to have little feel or need for proper controls and

checks on reliability, whereas those who like their facts

“hard” too often deny the depths and complexities of

mental functioning and thus avoid the excitement and

uncertainty that facing them entails (Stoller 1973, pp. x-xi).

Sally Y is a 25-year-old white single upper-middle-class woman

diagnosed as borderline by at least four psychiatrists.1

 In 5 years,

her intravenous heroin use escalated from occasional to weekend to

Type III escape (Wieder and Kaplan 1969), two to five bags daily. A

drug user of the Type III category is defined as one who “takes

drugs to escape the severe suffering of a chronically painful ego

state.”

When the Y’s first consulted me, it was not about Sally. She had

recovered from an acute psychotic episode some 18 months before,

precipitated by prolonged severe abuse of methaqualone and LSD.

Since then, Sally was living in a remote comer of the country,

apparently self-supporting and functioning, and the Y’s seemed

relieved at the outcome. In the aftermath of Sally’s decompensa1This report is based on the author’s 31⁄2-year psychotherapy of her parents,

Mr. and Mrs. Y, consultative evaluations of Sally and her sister, and ongoing

coordinating discussions with Sally’s present psychiatrist, Arthur M. Schwartz,

M.D., who has treated her for a year and a half.
KAPLAN: IMPLICATIONS FOR THERAPY 129

tion, however, Mrs. Y complained that “our family is falling apart

from depression.”

Her complaint narrowed down to a lack of emotional support

from her husband. I took him into thrice-weekly psychotherapy

with rationale that any improvement in Mr. Y’s impoverished objectrelationships would redound to his wife’s benefit as well. Mr. Y is a

controlling, unfeeling, obsessive-narcissistic character beneath a

smiling, easygoing facade. He readily admitted his avoidance of

any close, giving relationship, which stemmed from a fear of being

engulfed: “Give them a finger and they’ll want the whole arm.”

Part of his avoidance derived from early experiences with his

unempathetic borderline mother who had raised him by the book.

Whenever he had turned to his mother for understanding and support in childhood, her response was an admonitory lecture on

etiquette tangential to his immediate problem, with punishments

adding to his woes. His remote, narcissistic father was away “on

business” months at a time, and showed little interest when home.

Both Mr. Y’s parents were pathologically stingy. When he married, they rendered a bill for room and board since age 21 and for

the engagement party they had tendered. Mr. Y reacted to their

pathological parsimony with a combination of material overgenerosity and affectional stinginess. He supports his only sibling,

a younger brother. Mr. Y’s brother is a chronic drug abuser with

paranoid trends who hasn’t worked in 10 years. We were to learn

later that Mr. Y’s relationship with his brother was a prototype for

that with Sally.

Mr. Y hardly ever spoke of Sally, but after a year in therapy,

asked that I advise his wife about their daughter. Through these

consultations with Mrs. Y, it became clear to me that Sally was

probably reinvolved in chronic severe drug abuse. Furthermore,

Mr. Y not only denied her involvement, but abetted it. Encouraging Sally‘s phone calls to his office, Mr. Y sent her money without Mrs. Y’s knowledge.

Where Mr. Y used denial and avoidance and underreacted, his

wife is a pessimistic worrier who overacts with panic and selfblame. She is an infantile, dependent woman who herself suffered from maternal deprivation. She yearns for stability and

security because of childhood experiences with a long succession

of housekeepers and frequent moves all over the country. Mrs. Y

never completed an academic year in one school until her teens.

Mrs. Y’s mother immersed herself in the family business, but

periodically her neglect alternated with a self-centered need to

mother without regard for her child’s (Mrs. Y’s) needs. This immature, narcissistic, clinging grandmother dominated her daughter
130 PSYCHODYNAMICS OF DRUG DEPENDENCE

and the grandfather with hysterical outbursts indistinguishable from

tyrannizing temper tantrums.

When Mrs. Y married, she aspired to create the ideal family she

fantasied in childhood. Instead, she recreated the relationship with

her own mother, first with Mr. Y, then with Sally. Lacking selfesteem and devoid of any sense of entitlement, Mrs. Y asks: “Who

am I to want anything for myself? Who am I to stand in the way of

their desires and happiness?” This couple’s neurotic needs mesh, for

Mr. Y’s attitude is one of dominating helpless entitlement. He expects Mrs. Y to be at his beck and call: “She has nothing better to

do.” In effect, she is his buffer, insulating him from the world by

carrying out his commands. Mr. Y’s attitude is that of the young

child who deals with the threat of the loss of his sense of magic

omnipotence in the course of separation-individuation. Delegating

this power to the now separate mother, he yet retains anal-sadistic

domination of her.

Mr. Y is unable to purchase his own clothes or to select what to

wear in the morning. Mrs. Y must purchase and lay out his complete ensemble daily. She must attend to all the practical realities

of everyday life. Mr. Y never has refueled the car nor had it serviced; he has never been in a department store or a hardware store.

Yet Mr. Y knows what has to be done, daily preparing long lists of

chores for Mrs. Y, his imperial ambassador to the outside world.

Mrs. Y never objected, because in truth, she didn’t know what to

do with herself. Whenever her wifely and motherly duties were

complete, she retired to bed to read or daydream, content. At

once, she was the obedient little girl and the perfect all-giving wife

and mother for which that little girl had yearned.

Sally’s breakdown and hospitalization while at college shattered

Mrs. Y’s contentment. Robbed of her illusion of motherly perfection, she was wracked with self-blame. Furthermore, Mr. Y’s

emotional unavailability became so glaring that she could deny it

no longer. For just as he refused all dealings with merchants, gardeners and auto repair men, he would have nothing to do with the

hospital and the doctors. Of course, he was very interested, and

would make lists of questions for Mrs. Y to ask the doctors, but

the demands of his business precluded his personal involvement.

When Mrs. Y tearfully reproached him, Mr. Y would angrily

accuse her of overreacting, minimize Sally’s predicament, and present a list of social obligations she had neglected during the hospitalization. So I came to understand Mr. Y’s willingness to have his

wife consult me about Sally. When he could no longer deny her

problem, he sought to avoid it in customary fashion, by delegation

to Mrs. Y.
KAPLAN: IMPLICATIONS FOR THERAPY 131

Once Sally was brought to my attention, I rapidly inferred both

her serious drug involvement (without any certainty of heroin use)

and her marked dependency on her parents. However, Mr. Y would

deny the former and Mrs. Y was fearfully loathe to exercize the

leverage this dependency implied. Therefore, it took 6 months more

before the Y’s could bring themselves to insist that Sally return

home. Finally convinced that her financial dependence reflected a

profound emotional dependence upon them, the Y’s nevertheless

were surprised at her easy compliance with their summons home.

The pattern was repeated in the 4 additional months they took to

insist upon her consulting me. Though guarded in the interview,

Sally accepted my referral for psychotherapy with alacrity.

Mrs. Y had placed Sally in nursery school at 3 because she was

having a rough pregnancy. Sally cried a great deal, and her mother

often let her stay home. In subsequent years, the crying gave way to 

complaints of sore throats and “swollen glands.” Though Mrs. Y

was well aware that Sally’s complaints had no physical basis, she

could not insist that the child attend school those days.

Sally’s only sibling, a sister 3 years younger, manifested a severe

behavior disorder from age 2 to 6, with hyperactivity, hair-pulling

and trichophagia. During this 4-year period, 5 through 9, the

mother feels that Sally was seriously neglected. From 7 to 11, Sally

was treated for asthma, receiving weekly allergy shots and oral and

intramuscular medication for acute attacks.

After a series of asthmatic attacks at summer camp at age 11, the

parents were summoned. In their presence, the camp doctor accused

Sally of bringing the attacks on, and told her to say so directly if

she wished to go home. Mrs. Y was impelled to state that she would

never force Sally to remain. Confronted thus, Sally chose to stay,

suffering no further attacks.

Taking courage from the doctor’s example, her parents offered

Sally the dog long withheld on the basis of strong positive allergy

tests. Sally agreed to the proviso that the dog would be taken away

if she had another attack. None followed, and she’s had a dog ever

since.

According to her mother, Sally was a depressed, sluggish, unenthusiastic isolate from early childhood. Mrs. Y was always arranging

for other children to come over and play. Left to herself, Sally ate

candy and watched television, while the phone hardly ever rang. At

12, however, she went to a new camp. During the several summers

there, she was enthusiastic and a model of responsibility, especially

in caring for younger children. Sally got along well with the staff

also, but her peer relations remained poor. Once back home, she

reverted to sluggish isolation. Sally’s habit of lying on her bed for
132 PSYCHODYNAMICS OF DRUG DEPENDENCE

hours in a reverie appeared around this time. Although Mrs. Y had

long done the same, she had Sally checked several times for hypothyroidism.

Mrs. Y contrasts her two daughters. With her younger daughter,

she always knows where she stands, for Mrs. Y’s demands will

be met with either anger or compliance. Sally’s evasive indirection

and withdrawal, however, make her mother exceedingly anxious.

This is not only in response to Mrs. Y’s demands, moreover. In her

transference behavior, Sally exudes helpless neediness nonverbally,

implicitly expecting the other to decode and supply her wants.

Once in her teens, Sally flouted family rules, driving without a

license and ignoring curfews. Father denied the defiance while

mother was paralyzed into fearful ineffectuality. They nevertheless

took heart in Sally’s cracking her shell of isolation and withdrawal

in ninth grade. Unfortunately these peer relationships were, and

continue to be, based on drug abuse. Such relationships, based on a

shared. activity or interest, rather than a genuine interest in the

other person, are characteristic of early or pre-latency peer relationships.

As she prepared for college, Sally dealt with her separation

anxiety. At summer orientation, she met a boy and quickly made

arrangements to live with him. When this agreement fell through in

the fall, Sally immediately found a replacement with whom she

lived for over 2 years. Ned was a campus drug dealer who supplied

her first heroin. He slept with a gun under the bed and was mortally

afraid of needles. Yet, Sally found snorting unsatisfying compared

to the intravenous route. Beginning with a sense of entitlement and

self-reward, she enjoyed the excitement of setting up the works and

flushing the blood back and forth in the syringe.

Heroin use was only occasional at this time, yet Sally’s preference

for “downs"-methaqualone, diazepam, chlordiazepoxide and barbiturates (Tuinal)-has been consistent. She found no pleasure or

relief from “ups,” and psychedelics made her fear losing control.

Sally began to decompensate at the beginning of her third college

year. She was under greater stress as her studies became more rigorous, and her parents were increasing their criticism of her relationship with Ned. At first she visited a psychologist at home on weekends, and then entered analysis five times weekly in her college

town. Soon she became fragmented, regressed and depressed.

After 6 weeks in a psychiatric hospital, which diagnosed her as a

borderline personality with severe drug abuse, Sally spent 6 months

at home, receiving once weekly supportive psychotherapy. For the

next 21⁄2 years, she led a subsidized hippie existence, dependent on

“downs” and gradually increasing heroin use. Whenever money ran
KAPLAN: IMPLICATIONS FOR THERAPY 133

short, she called father collect at the office, making her requests

palatable by citing the needs of her organic food or pottery-making

business. By the time she returned home again and entered psychotherapy, Sally was physically dependent on heroin.

Sally formed a dependent transference, and has not missed more

than two sessions in 18 months. She comes a few minutes late to

avoid waiting, wearing her coat, and carrying a tote bag with oral

supplies-cigarettes, gum and candy. With the therapist’s first

absence, Sally signaled her exquisite intolerance of separation and

the quick shift to another need-satisfying object. She had to leave

on vacation first, so as not to be the one left behind. Before her

psychiatrist returned, Sally confessed her heroin use to her parents

for the first time.

Sally’s confession was less a plea for help in stopping heroin than

a response to her loss of oral supplies. She was flat broke. On Sally’s

return from hippiedom, Mrs. Y had taken over as in childhood,

finding Sally an apartment and a roommate and paying the rent.

Sally had made her own revisions quietly, moving in with a newfound boyfriend, a chronic heroin user of her own class and background. When everything had been expended for their combined

habits, Sally turned to her parents. To get back home that day,

she literally had to comb through her pockets for nickels and dimes

to buy a couple of gallons of gas.

Sally remained abstinent for about one month, but her boyfriend’s success in completing his studies and entering business

pierced her formidable narcissism. Moreover, Sally very likely felt

a separation threat, in fearing that his success would make him less

needful of her. The blow to her omnipotent wishes and fragile

self-esteem made her envious and resentful, and Sally reinitiated

the mutual seduction with heroin. Soon, she was using five bags

daily, and requiring two to “get off.” After the boyfriend’s business capital, a gift from his parents, was expended for heroin, Sally

embezzled several thousands of dollars.

Mrs. Y had become alarmed by her daughter’s more obvious

episodes of somnolence, neglect of her responsibilities and abuse

of family charge accounts. I drew the conclusion for Mrs. Y that the

patient must have relapsed and that her earlier confession amounted

to a plea for their intervention. Mrs. Y needed massive therapeutic

support to withstand her daughter’s evasiveness, lying and vituperative rage when accused. Mr. Y characteristically denied and disappeared. The mother lied to me in turn, claiming falsely that she

had canceled all her charge accounts. Finally, the exposure of

Sally’s embezzlements overcame Mr. Y’s denial, and the parents

painfully implemented my recommendation for hospitalization.
134 PSYCHODYNAMICS OF DRUG DEPENDENCE

Sally offered no significant opposition and withdrawal was

accomplished easily. Threats of and reactions to separation pervaded

this period, with Sally seeking to control her parents’ visits. If they

came, she was withdrawn or belligerent; if they asked to come, she

rejected them; but if they threatened not to visit, she pleaded for

their presence.

The physician in charge of the detoxification unit proceeded

with family therapy despite his knowledge of the preexisting therapeutic arrangements. He told the assembled family that they all

shared the blame for Sally’s addiction. The validity of his statement

was vitiated by his style and timing. Her sister was consumed with

guilt. When I had seen the sister over a year before, she had described her closeness and loyalty which kept her from revealing

Sally’s drug involvement to their parents. Her guilt was reinforced

by sibling rivalry. In reaction to Sally’s first breakdown, sister consciously resolved to become the opposite, rejecting the drug-using

long-hairs, and becoming the studious athlete. The motivation was

not only fear of drugs, but the wish to please the Y’s and prove that

they were not total failures as parents. Already mother’s favorite,

she also was trying unsuccessfully to dislodge Sally from her preferred status with father.

Parenthetically, the sister’s need to please her parents and fulfill

their aspirations was linked with a marked identity problem. She

didn’t know how much she did to fulfill her own wishes, how much

the wishes of others. Sister hates to feel lazy and is compelled to

keep busy, suggestive of a struggle against that to which Sally has

surrendered. Sister’s drug preferences reflect this struggle. In contrast to Sally, sister dislikes marihuana and prefers amphetamines,

for Type II coping: “I have a disorganized mind and go off on tangents. Speed concentrates it and I do much better studying and on

exams.”

Detoxification completed, Sally was transferred to another hospital where her therapist was completely in charge of her treatment.

The first weekend after the transfer, Mrs. Y made a suicide attempt

with sleeping pills after Mr. Y went off on a business trip in the face

of her bitter objections. I did not hospitalize Mrs. Y after her emergency room visit. In the next 2 weeks, she responded to small doses

of Navane as an antidepressant, and to interpretations of her

dependency.

I told Mrs. Y that she tried to satisfy her own intense dependency needs and fear of abandonment vicariously, through being the

ever-dependable satisfier of everyone else’s needs. She took care of

the family as she wished to be taken care of. Mrs. Y’s severe insomnia, symptomatic of her depression, abated for the first time in
KAPLAN: IMPLICATIONS FOR THERAPY 135

5 years. (Five years before Sally had been hospitalized, the maternal

grandmother had suffered a nervous breakdown, and the maternal

uncle had suicided.)

Mrs. Y’s responses to the interpretations also emphasized dependency and separation: “I had only two models for marriage-my

mother who clung to my father 24 hours a day, except once a week

when she got all her mothering in on me . . . and the perfect marriage of my uncle who lived around the comer. He treated his wife

as his sister (Mrs. Y’s mother) wanted to be treated-‘til one day,

after 25 years, he hung himself. All my mothering came from

maids, and they had to mother my mother, too . . . I feel as if my

motor has been restarted.” For the first time ever, Mrs. Y then

made independent plans for a weekend.

In her therapy sessions, Sally seems to be asking to be given, told,

fed, without directly asking. If her doctor is slow to respond, she

flushes, verges on tears, and asks how long before she’ll feel better.

Her enthusiasm and energy seem to run down within 10 minutes,

and her chronic dissatisfaction mounts. She gets angry and by the

end of the session seems sleepy. Sally chain smokes cigarettes and

chews gum throughout.

The therapist came early every morning with coffee and cake

until Sally’s weight gain (at least 15 lbs. in 2 months) became obvious. Sally seemed happy about the discipline when the cake was

discontinued. Discussions of her weight gain have led to associations about her sister, suggesting not only the rivalry with the lithe

and muscular sister but also identification with the mother withdrawn and self-preoccupied during the pregnancy with sister.

After detoxification, Sally received Triavil 4-25 qid, since reduced to 2-25, and gradually progressed to working during the day

and returning to the hospital at night. With each increment of

freedom she tested the limits: returning intoxicated from marihuana, smuggling in marihuana, refusing to attend the compulsory

patient meetings. Her therapist stressed that every wish she has

ever expressed at home has been gratified. Firm and distinct limits

are required so she can gradually learn to tolerate frustration, for

which she is praised. Sally’s relationship with the therapist seems

shallow and without curiosity, but the therapeutic alliance has

endured.

Sally was able to join her parents for long weekends several times

since her hospitalization. Each time the mother extended the weekend without notice, encroaching upon the therapy sessions. This

seems to repeat in microcosm Mrs. Y’s bitter childhood experience

of being pulled out of school every year to accompany her parents

so that she never completed an academic year in one place. For the
136 PSYCHODYNAMICS OF DRUG DEPENDENCE

first time, Sally was able to refuse their invitation, stating that

therapy had to come first. They felt compelled to leave her over

$50 in cash. Before they left, the therapist reviewed the reactions

she could anticipate. Though it was her own choice, Sally felt

deserted nevertheless and acted out. She entered her grandparents’

vacant apartment and took a hypodermic syringe and needle, but

told her therapist about it. In libidinal terms, Sally’s craving for

heroin is on an oral level of fixation. Sally’s oral problems began

with infantile colic, and the tendency to overeat was well established by latency. Sally’s aggressive orality is easily discernible in

her voracious overeating and marked weight gain, her habit of constantly chewing ice, her blistering vituperative cursing when angered,

and the oral attitudes of entitlement. Stealing is experienced as

taking what she needs and therefore what she should have.

The orality is a necessary but insufficient determinant of Sally’s

drug use. The specific effects of heroin in enhancing her preexisting

defense of withdrawal into reverie make it sought after for Type III

use. So far, Sally has made it clear that heroin helps her surmount

rage, oral envy and some ill-defined sexual impulses. In addition,

heroin is used when she has a strong sense of entitlement and selfreward for accomplishment.

Although Sally dislikes the amphetamine “high,” she uses them

infrequently, in a Type II coping pattern. When Sally makes plans,

she is very enthusiastic. As she encounters painful reality in attempting to implement her plans, her oral attitudes of entitlement and

magical omnipotence are painfully unfulfilled and her fragile selfesteem crumbles. Frustration, rage and depression mount, and she

may seek desperately to recapture activity magically through

amphetamines, to accomplish her goal effortlessly.

Identification with mother is very evident in this regard. Mother

has been unable to commit herself seriously to any activity outside

of the house. Her reaction to any challenge is to feel threatened and

to withdraw gracefully before she fails. So mother’s days have been

spent in limited volunteer and community activities; the few hours

Mrs. Y spends in bed with a book almost every morning or afternoon are the prototype of the patient’s reverie. Mother’s fear of failure is most prominent in her overinvolvement with Sally; her selfesteem goes up and down with the ups and downs of Sally’s condition.

Both Sally and her mother share the lack of a reservoir for selfesteem and resolve, requiring a constant oral inflow of support,

direction and encouragement. Recently Sally was galvanized into

registering for a specialized course by pressure from Mrs. Y and her

sister. Immediately, she hoped that the course would be canceled.
KAPLAN: IMPLICATIONS FOR THERAPY 137

After the first class, Sally dealt with her sense of abysmal ineffectuality by raging at her fellow students, questioning the usefulness

of the course, and then fell into a deep undrugged sleep in her

office for over 2 hours.

It is a commonplace report from abstinent drug abusers that they

have experienced subjectively the drugged state while under stress.

In Sally’s case at least, this is more than an evocation of the wishedfor drugged state. It is a continuation of a regressive withdrawal

maneuver traceable back to her childhood. The next day, a progressive sequence similarly traceable to a childhood prototype could

be discerned. Mrs. Y, borrowing courage from me as she had from

the camp doctor many years ago, presented Sally with the necessity

for a clear-cut choice. If the course was too much for her, it had to

be dropped immediately lest several hundred dollars of tuition be

forfeited. Sally chose to continue, and the past repeated itself; after

passing the course with flying colors, Sally rewarded herself with a

genuine heroin nod.

COMPARISON OF SALLY AND CLARA

The contributions to the clarification of borderline conditions

from Kernberg, Mahler, Masterson and others have been most useful

in understanding Sally and her parents. Her treatment has been

based on this understanding. As Kemberg puts it, the diagnosis of

borderline personality organization involves descriptive, structural

and genetic-dynamic considerations. Assessment of the character

pathology delineates the level and nature of instinctual development, superego development, defensive operations of the ego, and

the vicissitudes of internalized object relationships (1968). In this

metapsychological diagnostic context, Sally’s heroin abuse is a

facet of failure of resolution of the separation-individuation process

typical of borderlines. She is an incomplete person, unable to maintain self-regulation. Her psychological homeostasis requires an

attachment to external objects to supplement the structural defects;

in Sally’s case, the objects include drugs as well as people.

It must be emphasized, however, that borderline personality

organization is not invariably associated with drug abuse. The importance of a detailed diagnostic assessment is illustrated by comparing Sally with Clara, another 25-year-old borderline woman who

is terrified of drugs. While Sally manifests direct and unrestrained

gratification of her fixation at the oral level, Clara shows evidence

of incomplete advances to higher libidinal stages. Clara’s significant
138 PSYCHODYNAMICS OF DRUG DEPENDENCE

oral, anal and negative Oedipal fixations are defended against by a

constant, fearful preoccupation with losing control.

Both patients were overweight children. Sally reacts with oral

envy of her younger sister; Clara has always protested loudly and

successfully against parental attention directed to her younger

brother and sister, and insists on the choicest morsel of any food.

In early adolescence, Sally’s oral indulgence extended to drugs; drug

satiation curbed her desire to eat, enabling her to lose some weight.

At the same developmental milestone, Clara unveiled severe primitive defenses against her oral impulses.

Clara could never eat alone, except at home in the context of

compulsive rituals. In the 3 years at a local commuting college

(following her acute breakdown at an out-of-town school), she

came home daily for lunch, never once entering the college cafeteria.

Clara could eat out with her family or boyfriends (regarded as

“meal tickets”). They had to help overcome her painful indecision

with the expensive menu. Whenever she violated a food ritual, Clara

was gripped in the almost delusional conviction of instantaneous

obesity; days passed before she summoned the courage to weigh

herself. But first she had to use a laxative and a depilatory, to shave

down the ounces.

Clara regarded food as a kind of poison. The compulsive rituals

which protected her against the poison were subjectively experienced as external controls, substituting for the controlling symbiotic object. Drugs were regarded similarly, as poisons which

would erode her controls. Alcohol was excepted; Clara considered

liquor not as a drug-poison, but as a ritual relaxant potion (two

drinks on an empty stomach) to overcome strong inhibitions in

heterosexual relationships.

Unlike the situation with Mrs. Y, who was consistently fearful

and placatingly indulgent of Sally, the control would shift back

and forth between Clara and her mother in their symbiotic dyad.

This exchange of roles between mother and child was the prototype

of Clara’s two kinds of heterosexual relationships: controlling and

cruel with the nice, passive men; submissive and masochistic with

the dominating, cruel ones.

Sally used her “downs,” including heroin, with a sense of domination deriving from that exerted over her parents, to reinforce a

regressive narcissistic withdrawal from real objects into a state of

self-sufficient omnipotence. Peer relations were based primarily on

the shared interest in the drug. Clara, somewhat more advanced in

separation-individuation, felt herself separate and weak and yearned

for a symbiotic relationship. After years of superficial heterosexual

promiscuity combined with conscious homosexual attraction to her
KAPLAN: IMPLICATIONS FOR THERAPY 139

mother’s most feminine friends, Clara fell in love with a girl her

own age. In this lesbian relationship, the love object represented a

fusion of the idealized self and the idealized mother. Clara’s strong

masculine identifications, to the fore in her active courting, receded

in the actual lovemaking, in which the yearned-for symbiotic

merger was enacted.

Both patients have exquisitely vulnerable narcissistic self-esteem

regulation, subject to abrupt deflation into. the abyss of utter

worthlessness. Both scramble frenetically for external supplies to

restore self-esteem by recapturing the sense of omnipotence. They

turn to different sources, however. Sally’s source is heroin, while

Clara obtains narcissistic supplies from a variety of object relationships. The therapeutic prerequisite with Sally is to block her reliance on heroin, leaving no choice but the substitution of proferred

object relationships. This, in effect, forces her into a predicament

comparable to Clara’s,. Only then can the pathological immaturities

be confronted.

DISCUSSION OF TREATMENT

A modification of psychoanalytic psychotherapy suitable for

borderline patients described by Kemberg (1968) includes systematic analysis of the negative transference in the here-and-now, and

promotion of the observing function of the ego in a structured

therapeutic situation which sets limits and blocks acting out of the

transference. The limits imposed include the suppression of drug

taking.

These represent the basic conditions promoting change and

growth in therapy. Classical analysis unmodified provokes regression and acting out which is either too gratifying or disorganizing

to be utilizable in treatment. By contrast, the excessively rigid and

controlled structure of some mass treatment programs may send

the negative transference underground. Suppression of the symptom in such a setting may derive from identification with the

aggressor in the form of a personified introject; or it may be an outward compliance without genuine change. In either case, the potential for relapse is obvious.

Sally has a long way to go in her treatment, but significant advances have been made in fashioning conditions favoring an eventual

positive outcome. Her parents continue active participation in therapy so that paternal denial and maternal fearfulness no longer provide oral gratification without limit setting. Hitherto, Sally could

conceal, from herself and others, her profound dependency on her
140 PSYCHODYNAMICS OF DRUG DEPENDENCE

parents by her ability to obtain their gratification of her dependent

needs and by the ease with which she shifted from one superficial

need-satisfying object relationship with boyfriends to another.

Sally’s drug use cannot be considered satisfactorily suppressed, despite the utilization of professionally trained companions, so that

the more strictly supervised setting of a drug treatment center or

psychiatric hospital will be required before she can come to grips

with the issues Kernberg stresses.

In conclusion, heroin abuse is symptomatic behavior. Nomothetic

generalization about “the heroin addict” presses a false facade of

uniformity upon a population heterogeneous in type of use, etiology, personality organization, amenability to different forms of

psychotherapeutic intervention and prognosis. This presentation has

focused upon the subgroup of borderline personalities who employ

heroin in Type III use. The rational approach to a specific prescription of therapy in heroin use is through the careful metaphychological diagnosis of the personality of the heroin user. The patient is

more than a heroin user; he is an individual with his own particular

constellation of psychopathology which includes taking heroin.

REFERENCES

Deutsch, H. Some forms of emotional disturbance and their relationship to

schizophrenia. Psychoanal Q, 11:301-321, 1942.

Freud, S. On Narcissism. (1914) SE 14:67-102. London: Hogarth Press,

1957a.

Mourning and Melancholia. (1917) SE 14:243-258. London: Hogarth

press, 19576.

Grinker, R.R., Sr., Werble. B., and Drye, R.C. The Borderline Syndrome. New

York: Basic Books, 1968.

Hoch, P., and Polatin, P. Pseudoneurotic forms of schizophrenia. Psychiatric Q,

23:248-276, 1949.

Kernberg, 0. The treatment of patients with borderline personality organization. Int J Psychoanal, 40:600-619, 1968.

Knight, R.P. Borderline states. Bull. Menninger Clinic, 17:1-12, 1953.

Loewenstein, R.M., Newman, L., Schur, M., and Solnit, A.J., eds. Psychoanalysis-A General Psychology. New York: Int. Univ. Press, 1966.

Minuchin, S., Montalvo, B., Guervey, B.C., Jr., Rosman, B.L., and Schumer, T.

Families of the Slums, An Exploration of their Structure and Treatment.

New York: Basic Books, 1967.

Pavenstedt, E. The Drifters: Children of Disorganized Lower Class Families.

Boston: Little, Brown, 1967.

Pfeiffer, E. Disordered Behavior: Basic Concepts in Clinical Psychiatry. New

York: Oxford Univ. Press, 1975.

Schmideberg, M. The borderline patient. In: American Handbook of Psychiatry, S. Arieti, ed., 1:398-418. New York: Basic Books, 1959.
KAPLAN: IMPLICATIONS FOR THERAPY 141

Stoller, R.J. Splitting: A Case of Female Masculinity. New York: QuadrangleN.Y. Times Book Co., 1973.

Wieder, H., Kaplan, E.H., Drug use in adolescents: Psychodynamic meaning

and pharmacogenic effect. Psychoanal Study Child, 24:399-431, 1969.

Yorke, C. A critical review of some psychoanalytic literature on drug addiction. Br J Med Psychol, 43:141-159, 1970.
CHAPTER 10

Ego Functions in Drug Users

William A. Frosch, M.D., and Harvey Milkman, Ph.D.

Multidrug experimentation, particularly by adolescents, and

polydrug abuse have recently become foci of professional attention,

at times to the exclusion of investigating preferential drug use and

abuse. Although it is clear that many users go through a period of

testing and trying, at least some settle on a specific preferred drug.

This choosing, clearly in part socially determined (e.g., by availability, peer approval, etc.), must also tell us something of importance concerning personality and perhaps physiologic variables

determining drug choice, abuse, and maintenance in the drug subculture.

These considerations led us to select a group of drug abusers with

strong stated preference for either heroin or amphetamine and to

examine selected aspects of personality structure under both abstinent and preferred intoxicated conditions. Using Bellak and Hurvich’s (1969) Interview and Rating Scale for Ego Functioning,

“preferential” users of heroin (N=10 or amphetamines (N=10)

were interviewed under conditions of abstinence and intoxication

with their respectively chosen drug. Normals (N=10) were interviewed twice while abstinent. Data were analyzed, qualitatively and

quantitatively, to answer: a) how do preferential users differ from

normals and each other under abstinent conditions, b) how do they

differ under conditions of intoxication, c) how does the drug user

differ within himself under conditions of abstinence and intoxication?

Kramer’s (1967) notion of preferential use was applied and

supported. In a sample of more than 30 drug admissions to Bellevue

Psychiatric Hospital, more than 75 percent stated a specific preference for either heroin or amphetamine. All subjects had experienced both drugs, but the majority stated a strong preference and

142
FROSCH AND MILKMAN: EGO FUNCTIONS IN DRUG USERS 143

prolonged involvement with either heroin or amphetamine. The

criteria for drug dependence were intravenous administration and

minimal levels of use in the past month (amphetamines, more than

nine times; heroin, more than five times). Subjects were white,

male, middle class, 20-30 years of age, and nonpsychotic. Each

heroin user was interviewed while abstinent and under the influence

of 15 mg. morphine, given intramuscularly, in a clinical setting.

Amphetamine users were interviewed while abstinent and intoxicated with 30 mg. (oral) dextroamphetamine sulfate, also in a clinical setting. Normals were used as a control and interviewed twice

while abstinent. Abstinence was determined by self-report and urine

analysis. Interviews were spaced 1 to 2 weeks apart, taped, and the

interviewer was blind to subject types and conditions of intoxication. The results pertain to a specific type of drug-using population

(white, middle class) but may also be applicable to minority groups.

Initial impressions suggested distinct relationships between personality style and drug preference (Milkman and Frosch 1973). The

amphetamine abuser coped with his difficulties with an inflated

sense of self-worth and active confrontation with his environment.

The heroin abuser was consciously depressed and despairing, and

withdrew from an environment perceived as hostile and threatening.

Each subject participated in two semistructured interviews and

was rated in accord with Bellak and Hurvich’s (1969) Interview and

Rating Scale for Ego Functioning. Scoring yields a composite quantitative index of “general adaptive strength,” as well as specific

scores for degree of impairment in each of 11 specified ego functions: 1) Autonomous Functioning, 2) Synthetic-Integrative Functioning, 3) Sense of Competence, 4) Reality Testing, 5) Judgment,

6) Sense of Reality, 7) Regulation and Control of Drives, Affects

and Impulses, 8) Object Relations, 9) Thought Processes, 10) Defensive Functioning, and 11) Stimulus Barrier. The scale also provides

measures for Libidinal and Aggressive Drive strengths. (See figures

1, 2, and 3. Because Stimulus Barrier ratings are qualitative, i.e.,

high, medium, or low, rather than quantitative, this variable is

omitted from the figures.) Ratings are calculated on a 13-point system with each ego function subscale (e.g., reality testing) constructed such that a low rating indicates maladaptive functioning,

and a score of 9 or higher indicates the normal range. Scales for

drive strengths differ in that a middle score of 7 is considered adaptive while low scores reflect excessive drive strength and high scores

reflect insufficient drive strengths.

The test data were submitted to analyses of variances for comparison of heroin and amphetamine users, under abstinent and

intoxicated conditions, with a control group of unintoxicated
Fig. 1. Mean ego function ratings for amphetamine S’s, heroin S’s, and normals in the abstinent

condition with ratings for libidinal and aggressive drive strengths.

High score reflects lower strength drive. †

p ( .05 (amphetamine vs. heroin)
Fig. 2. Mean ego function ratings for heroin users in abstinent and intoxicated conditions with scores

for libidinal and aggressive drive strength. (N = 10)

High score reflects low drive strength p<.05
Fig. 3. Mean ego function rating for amphetamine users in abstinent and intoxicated conditions

with scores for libidinal and aggressive drive strength. (N=10)

High score reflects low drive strength p<.05
FROSCH AND MILKMAN: EGO FUNCTIONS IN DRUG USERS 147

normals. Under the abstinent condition, both drug-using populations

showed subnormal ego function ratings in most categories. With the

exception of Reality Testing, amphetamine users exhibited significantly higher ego strength than heroin users, whether or not they

were intoxicated. There were no statistically significant differences

between normal and amphetamine users, and Libidinal Drive Strength

did not show significance under any of the comparisons made. In

most cases ego functioning was lower in the intoxicated condition

with significant differences observed for three variables.

Although relative to heroin users, ego functioning is more adaptive in amphetamine users when both groups are in the intoxicated

condition, one cannot, unequivocally, extend this finding outside

of the laboratory situation. Experimental doses of 30 mg. and

15 mg. for amphetamine and heroin users, respectively, may not

be comparable in effect to average “field” doses of 310 mg. and

100 mg. Even at our reduced dose range, however, the results suggest a trend, in both groups, for ego functioning to be negatively

affected by the utilization of their respective drugs. Six of the 10

means observed-for-heroin users are lower in the intoxicated condition. Eight of the 10 means observed-for-amphetamine users are

lower in the intoxicated condition. There are four cases in which

ego functioning is significantly lower in the intoxicated. condition:

Regulation and Control of Drive, Affect and Impulse (for both

groups), Judgment (for amphetamine users), Sense of Competence

(for heroin users). A nearly significant result is observed for Reality

Testing (this function is lower for both groups in the intoxicated

condition). It is expected that under conditions of higher doses,

greater impairment of ego functioning may be observed and more

significance obtained.

For the purposes of this presentation, we will only discuss a

selection of the measured individual ego functions. The full data

will be available elsewhere (Milkman and Frosch, in press).

Autonomous Functioning is assessed according to the degree of

impairment of apparatuses of primary autonomy (functional disturbances of sight, hearing, intention, language, memory, learning

or motor function) and secondary autonomy (disturbances in habit

patterns, learned complex skills, work routines, hobbies and interests). While amphetamine users are relatively unimpaired in this

area, heroin users are subject to moderately high interference, by

conflict, of their apparatuses of primary and secondary autonomy.

Interview material revealed specific problems in concentration with

difficulty carrying out routine tasks and skilled behaviors.

Sense of Competence is based on the subject’s overt, conscious

statement of his feelings of adequacy. No attempt was made at
148 PSYCHODYNAMICS OF DRUG DEPENDENCE

assessing the underlying dynamics for this statement (e.g., unconscious denial of helplessness, etc.). Scores reflect the person’s expectation of success or the subjective experience of actual performance

(how he feels about how he does and what he can do). Amphetamine users have a significantly higher Sense of Competence across

both interview conditions. Although there is no significant drug

effect for amphetamine users on this variable, the obtained mean is

higher in the intoxicated condition. While amphetamine appears to

bolster feelings of adequacy, heroin seems to have the opposite

effect. The amphetamine user denies feelings of helplessness and

inadequacy; the heroin user is prone to accept feelings of hopelessness and despair. These findings are consistent with clinical impressions that the amphetamine user is grandiose and the heroin user is

concerned with survival and self-maintenance.

Judgment evaluates the subject’s anticipation of the consequences

of intended behaviors (legal culpabilities and social censure, disapproval or inappropriateness) and the extent to which manifest

behavior reflects the awareness of these consequences. Amphetamine users show significantly more adaptive Judgment than heroin

users across both interview conditions. Although drug intoxication

does not significantly impair the Judgment of heroin users in this

situation, amphetamine users show a significant decrement in their

judgmental capacity while under the influence of amphetamine.

The heroin user’s Judgment is so defective that he repeatedly encounters danger in health, work and interpersonal relationships.

Although he may verbally anticipate the consequences of his

actions, manifest behavior rarely reflects this awareness. For the

amphetamine user, poor Judgment usually occurs in fairly encapsulated or conflict-related areas.

Sense of Reality rates the extent to which external events are

experienced as real and as being embedded in a familiar context;

the extent to which the body and its functioning are experienced as

familiar and unobtrusive; the degree to which the person has

developed individuality and self-esteem. The data show significant

differences between heroin and amphetamine users across both

interview conditions. The heroin user appears as an individual of

quasi-stable sense of identity dependent on outside sources. When

external signals and cues are absent, identity can become poorly

integrated. Occasional derealization and depersonalization are

observed with some unrealistic feelings about the body. In most

cases self-esteem is low. The amphetamine user is less dependent on

environmental feedback, and depersonalization-like phenomena are

more likely to occur under unusual conditions (falling asleep, drugs,

radical environmental changes). The heroin user’s need for external
FROSCH AND MILKMAN: EGO FUNCTIONS IN DRUG USERS 149

regulation of self-esteem is seen as a potent factor in the relative

success of the therapeutic community. Peer pressure is generated

to support nonaddictive behavior. For an individual lacking in a

sense of independent identity, the group ideal is easily adopted and

until the user returns to his former community, his drug taking and

criminal activity may be curtailed.

Regulation and Control of Drive, Affects and Impulses refers to

the directness of impulse expression and the effectiveness of delay

and control mechanisms; the degree of frustration tolerance and the

extent to which drive derivatives are channeled through ideation,

affective expression and manifest behavior. Amphetamine users are

significantly higher than heroin users under intoxicated and abstinent conditions. Both groups display significantly less Regulation

and Control of Drive, Affects and Impulses in the intoxicated condition. The significant drug effect for this function is particularly

interesting because it suggests that under intoxication both groups

might be expected to have less impulse control and present a greater

danger to themselves and/or the community. The heroin user

appears as an individual given to sporadic rages, tantrums or binges.

Periods of overcontrol may alternate with flurries of impulsive

breakthroughs. This may be observed dramatically when the user

voluntarily submits himself to extended periods of increased environmental structure, in drug programs, where impulse expression is

minimized. Temporarily the user appears to have adequate impulse

control. Suddenly and without warning, however, impulses gain the

upper hand and the user is seen on a self-destructive binge. Disciplinary action is taken and once again impulses are quieted through

self-regulation, authoritative, and peer pressures. The cycle tends to

repeat.

For the amphetamine user, impulse expression is less direct, pervasive and frequent. Aggressive behavior is more often verbal than

physical and fantasies predominate over unusual behavior. Manifestations of drive-related fantasies are seen in quasi-artistic productions such as “speed freak” drawings where primitive and threatening fantasies are portrayed through massive expenditures of compulsive energy. The amphetamine user may sit for hours drawing

frightened faces, decapitated bodies, etc.

Object Relations takes into account the degree and kind of

relatedness to others; the extent to which present relationships are

adaptively patterned upon older ones; the extent of object constancy. Amphetamine users are significantly more effective in

Object Relations than heroin users, across abstinent and intoxicated

conditions. It is interesting to note that for heroin users, the obtained mean for this function is higher in the intoxicated condition.
150 PSYCHODYNAMICS OF DRUG DEPENDENCE

Perhaps in this dose range, heroin tends to reduce anxiety and

allows for a smoother and more relaxed communication between

people. This notion supports Hartmann’s (1969) observation that

“there is an attempt to overcome the lack of affectionate and meaningful object relations through the pseudo-fusion with other drug

takers during their common experience.” The heroin user is generally detached from people while under stress, and strives for nurturant relationships, of a dependent nature, leading to stormy or

strained attachments. The amphetamine user, although more successful in Object Relations, tends to become involved in relationships with strong, unresolved Oedipal elements. Castration concerns

tend to manifest themselves in unusual and extreme sexual behaviors, such as Don Juanism and homosexuality. Underlying concerns

about masculinity and adequacy are expressed through compulsive

sexual activity and a boasting attitude of sexual prowess and

potency. Relationships may, however, endure for long periods of

time, although they rarely have the stability and sustaining power

of the idealized marital situation.

Stimulus Barrier indicates the subject’s threshold for, sensitivity

to, or awareness of stimuli impinging upon various sensory modalities; the nature of responses to various levels of sensory stimulation

in terms of the extent of disorganization, withdrawal or active

coping mechanisms employed to deal with medium or low Stimulus

Barriers. Amphetamine users have significantly higher Stimulus

Barriers than heroin users in the abstinent condition. Examination

of the raw data revealed that 6 of 10 amphetamine users interviewed were rated high on this variable and 9 of 10 heroin users

were rated low. The data tend to support Ellinwood’s (1967) suggestions concerning biological predilections for certain drugs.

Although it may be argued that long-term involvement with particular drugs may have specific effects on stimulus thresholds, Stimulus

Barrier is considered to be the most constitutionally based ego

function (Bellak and Hurvich 1969). The data suggest that amphetamine users, with biologically high thresholds for excitatory stimulation, are seeking homeostasis through self-medication. Amphetamine seems to put the user into closer touch with environmental

stimuli which might otherwise be unavailable because of constitutionally based high Stimulus Barriers. Conversely, the heroin user

may have a predisposition toward excessive vulnerability to environmental stimuli. He seeks to raise stimulus thresholds, allowing more

adaptive function in a world of relatively painful and extreme

stimulation.

Aggressive Drive Strength assesses: overt aggressive behavior

(frequency and intensity); associated and substitute aggressive
FROSCH AND MILKMAN: EGO FUNCTIONS IN DRUG USERS 151

behavior (verbal expressions, etc.); fantasies and other ideation;

dreams; symptoms, defenses and controls. Heroin users have significantly higher Aggressive Drive Strength than amphetamine users

across both interview conditions. There is no apparent difference

between normals and amphetamine users on this variable. The

heroin user is seen as an individual whose overt acts of aggression

are considerably more intense and frequent than average. The

presence of physical assaultiveness and multiple suicide gestures is

common. Hostile punning and witty repartee are often observed.

It is speculated that the relative success of residential treatment

programs is related to this phenomenon. Intensive confrontation

in group therapy (a major treatment modality in drug programs)

provides an outlet for excessive aggressive energy. Violent verbal

expressions are often encouraged and readily tolerated, thus reducing the user’s tendencies toward repression and withdrawal. This

approach seems to be effective in decreasing the heroin user’s

potential for overt violence of an inner and outer directed nature.

For the amphetamine user, aggressive energy appears to be less

excessive and is channeled more adaptively. Periodic breakthroughs

of violence occur, but, with the exception of amphetamine psychosis, these expressions are usually not as frequent or intense as the

heroin user’s. Fantasies of violence are usually expressed verbally

and sometimes find their expression through identification with

radical political groups. This finding, greater hostility in heroin

addicts than amphetamine abusers, is echoed in a recent study

(Gossop and Roy 1976) using different scales and a different

population.

DISCUSSION

Although the observations for this study were made while male

users were under abstinent and somewhat intoxicated conditions,

it must be recalled that our subjects had all been heavy drug users

for several years. It is, therefore, difficult to know if our findings

represent a factor in the etiology of the pattern of drug use or the

result of such drug use and its imposed life patterns. However,

quantitative analyses and clinical impressions provide a framework

for conceptualizing possible psychological differences between preferential users of heroin and amphetamine. Some speculate that

these differences are related to early, pre-drug patterns of childhood

experiences.

Having once experienced a particular drug-induced pattern of ego

functioning, the user may seek it out again for defensive purposes
152 PSYCHODYNAMICS OF DRUG DEPENDENCE

as a solution to conflict or for primary delight. This seeking out of

a special ego state will be related to the individual’s previous needs

for the resolution of conflict or anxiety. If a particulardrug-induced

ego state resolves a particular conflict, an individual may seek out

that particular drug when in that conflict situation. This will result

in preferential choice of drug.

Wieder and Kaplan (1969) define the altered ego state induced

by opiates as “blissful satiation.” As Savitt (1963) points out, the

elation produced by these drugs has been stressed out of proportion

to the sleep or stupor which follows. The transient euphoria preceding the stupor may be related both to the decreased pressure of the

drives, libidinal and aggressive, and to the sense of gratification of

needs. The user “seeks desperately to fall asleep as a surcease from

anxiety and the drug provides obliteration of consciousness. Well

expressed in the vernacular, the addict ‘goes on the nod.’ ”

The heroin user, who characteristically maintains a tenuous equilibrium via withdrawal and repression, bolsters these defenses by

pharmacologically inducing a state of decreased motor activity,

under-responsiveness to external situations and reduction of perceptual intake: “. . . [a] state of quiet lethargy . . . [is] . . . conducive to hypercathecting fantasies of omnipotence, magical wish

fulfillment, and self-sufficiency. A most dramatic effect of drive

dampening experienced subjectively as satiation may be observed in

the loss of libido and aggression and the appetites they serve”

(DeQuincey 1907, p. 79).

Though, as expected, the dramatic effects outlined above were

not brought on by our low level, experimental dose, the observed

data points in a parallel direction. Elevated scores for Object Relations, and Sense of Reality, suggest greater relaxation and less pressure from the drives. Though not significantly lower, the mean

score for Libidinal Drive Strength points to a dampening of sexual

appetite. Wieder and Kaplan further point out that this style of

coping is reminiscent of the Narcissistic Regressive Phenomenon

described by Mahler (1967), as an adaptive pattern of the second

half of the first year of life. It occurs after the specific tie to the

mother has been established and is an attempt to cope with the

disorganizing quality of even her brief absences. It is as if the child

must shut out affective and perceptual claims from other sources

during the mother’s absence. This formulation is consistent with

earlier remarks by Fenichel (1945). Addicts are “fixated to a

passive-narcissistic aim” where objects are need-fulfilling sources of

supply. The oral zone and skin are primary, and self-esteem is

dependent on supplies of food and warmth. The drug represents

these supplies. Addicts are intolerant of tension and cannot stand
FROSCH AND MILKMAN: EGO FUNCTIONS IN DRUG USERS 153

pain or frustration. In our study, the notion of low pain thresholds

is supported by the observation that 9 of the 10 heroin users interviewed received a “low” rating for Stimulus Barrier. Drug effects

alleviate these difficulties by reproducing the “earliest narcissistic

state.” The specific need gratification of the passive-narcissistic regression reinforces drug-taking behavior.

The overall decrement in ego functioning (which is clearly observed in our study, even at this low dose) and the pressures of

physiological dependency, however, set the groundwork for a

vicious cycle. The heroin user must increasingly rely on a relatively

intact ego to procure drugs and attain satiation, Ultimately he is

driven to withdrawal from heroin by the discrepancy between intrapsychic needs and external demands. Hospitalization, incarceration

or self-imposed abstinence subserve the user’s need to resolve his

growing conflicts with reality.

In contrast to heroin and other sedative drugs, amphetamines

have the general effect of increasing functional activity. Extended

wakefulness, alleviation of fatigue, insomnia, loquacity and hypomania are among the symptoms observed. Subjectively there is an

increase in awareness of drive feelings and impulse strength as well

as heightened feelings of self-assertiveness, self-esteem and frustration tolerance. Though not statistically significant, our observations

support most of these generalizations. Amphetamine intoxication

produced in our subjects elevated scores on Autonomous Functioning and Sense of Competence. Interview material suggests a feeling

of heightened perceptual and motor abilities accompanied by a

stronger sense of potency and self-regard.

As in the case of heroin, the alterations induced by amphetamine

intoxication are syntonic with the user’s characteristic modes of

adaptation. This formulation is in agreement with the observations

of Angrist and Gershon (1969) in their study of the effects of large

doses (up to 50 mg./hour) of amphetamine: “. . . it appears that in

any one individual, the behavioral effects tend to be rather consistent and predictable. . . . Moreover these symptoms tended to be

consistent with each person’s personality and ‘style.’ ”

Energizing effects of amphetamine serve the user’s needs to feel

active and potent in the face of an environment perceived as hostile

and threatening. Massive expenditures of psychic and physical

energy are geared to defend against underlying fears of passivity.

Wieder and Kaplan (1969) suggest that the earliest precursor to the

amphetamine user’s mode of adaptation is the “practicing period”

described by Mahler (1967). This period “culminates around the

middle of the second year in the freely walking toddler seeming to

feel at the height of his mood of elation. He appears to be at the
154 PSYCHODYNAMICS OF DRUG DEPENDENCE

peak of his belief in his own magical omnipotence which is still to a

considerable extent derived from his sense of sharing in his mother’s

magic powers.” There is an investment of cathexis in “the autonomous apparatuses of the self and the functions of the ego; locomotion, perception, learning.”

Our subject’s inflated self-value and emphasis on perceptual

acuity and physical activity support the notion that amphetamine

use is related to specific premorbid patterns of adaptation. The consistent finding that ego structures are more adaptive in the amphetamine user than they are in the heroin user suggests that regression is

to a later phase of psychosexual development.

Reich’s (1960) comments on the “etiology of compensatory narcissistic inflation” may provide further insight into the personality structure of amphetamine users. “The need for narcissistic inflation arises

from a striving to overcome threats to one’s bodily intactness.” Under

conditions of too frequently repeated early traumatizations, the primitive ego defends itself via magical denial. “It is not so, I am not helpless, bleeding, destroyed. On the contrary, I am bigger and better

than anyone else.” Psychic interest is focused “on a compensatory

narcissistic fantasy whose grandiose character affirms the denial.”

The high level artistic and political aspirations witnessed in our subjects appear to be later developmental derivatives of such infantile.

fantasies of omnipotence. Although the amphetamine user subjectively experiences increments in functional capacity and self-esteem,

biological and psychological systems are ultimately drained of their

resources. As in the case of heroin, our study points to an overall

decrement in ego functioning under the influence of amphetamine.

The recurrent disintegration of mental and physical functioning is

a dramatic manifestation of the amphetamine syndrome.

Recent workers (Hekimian and Gershon 1968) have typically

focused on the seemingly indiscriminate use of a variety of psychotropic agents. Multiple drug abuse or “status-medicamentosis”

(Wahl 1967) has been well documented. By viewing the problem

from the perspective of preferred drug used, we have defined differences between users, but note many basic similarities. An underlying sense of low self-esteem is defended against by the introduction of a chemically induced altered state of consciousness. The

drug state helps to ward off feelings of helplessness in the face of

a threatening environment. Pharmacological effect reinforces

characteristic defenses deployed to reduce anxiety. Drugged consciousness appears to be a regressive state which is reminiscent of,

and may recapture, specific phases of early child development.

The continuing controversy over how to treat whom among

drug users is evidence of our lack of understanding of factors
FROSCH AND MILKMAN: EGO FUNCTIONS IN DRUG USERS 155

which act to maintain drug users in the drug world. We know relatively little about the inner needs and wishes of drug users or about

the details of the ways drug use satisfies those needs and wishes.

Differences in personality structure and function, such as those we

describe in preferential users of heroin and amphetamine, may provide clues which would permit careful delineation of a variety of

treatment programs designed to meet the needs of a particular

group of drug users. Prediction of the appropriateness of a particular user to a specific treatment program would increase the likelihood of the user remaining in treatment and increase the likelihood

of successful outcome. Choosing the right drug in treating infection

or psychosis is recognized as important, often crucial; we suggest a

likely parallel in the treatment of drug use.

A successful treatment program must provide the user with alternative modes of satisfying those inner needs and wishes previously

resolved through drug use. Such alternative modes may include new

patterns of discharge, gratification, or defense. The design of such

programs requires more detailed knowledge than is currently available. Most workers have tended to lump together, rather than to

distinguish between, forms of drug use. In addition to such variables as the ego functions reported here, studies of cognitive style

and of physiologic responsiveness are likely to prove important.

REFERENCES

Angrist, B., and Gershon, S. Amphetamine abuse in New York City, 1966-

1968. Semin Psychiat, 1:195-207, 1969.

Bellak, L., and Hurvich, M. A systematic study of ego functions. J Nerv Ment

Dis, 148:569-585, 1969.

DeQuincey, T. Confessions of an English Opium-Eater. New York: E.P. Dutton,

1907. p. 79.

Ellinwood, E.H. Amphetamine psychosis: I. Description of the individuals and

process. J Nerv Ment Dis, 144:273-283, 1967.

Fenichel, 0. The Psychoanalytic Theory of Neurosis. New York: Norton, 1945.

Gossop, M.R., and Roy, A. Hostility in drug dependent individuals: Its relation

to specific drugs, and oral or intravenous use. Br J Psychiatry, 128:188-

193, 1976.

Hartmann, D. A study of drug-taking adolescents. Psychoanal Study Child,

24:384-397, 1969.

Hekimian, L.J., and Gershon, S. Characteristics of drug abusers admitted to a

psychiatric hospital. JAMA, 205:125-130, 1968.

Kramer, J.C., Fischman, V.S., and Littlefield, D.C. Amphetamine abuses.

Patterns and effects of high doses taken intravenously. JAMA, 201:305-

309, 1967.

Mahler, M. On human symbiosis and the vicissitudes of individuation. J Am

Psychoanal Assoc, 15:740-760, 1967.
156 PSYCHODYNAMICS OF DRUG DEPENDENCE

Milkman, H. and Frosch, W.A. On the preferential abuse of heroin and amphetamine. J Nerv Ment Dis, 156:242-248, 1973.

. The Drug of Choice. J Psychedelic Drugs, Vol. 9, Issue 1, in press.

Reich, A. Pathologic forms of self-esteem regulation. Psychoanal Study Child,

15:215-232, 1960.

Savitt, R.A. Psychoanalytic studies on addiction and ego structure in narcotic

addiction. Psychoanal Q, 32:43-57, 1963.

Wahl, C.W. Diagnosis and treatment of status medicamentosis. Dis Nerv Syst,

28:318-322, 1967.

Wieder, H. and Kaplan, E.H. Drug use in adolescents. Psychodynamic meaning

and pharmacogenic effect. Psychoanal Study Child, 24:399-431, 1969.
CHAPTER 11

Psychiatric Aspects of Opiate

Dependence: Diagnostic and

Therapeutic Research Issues

George E. Woody, M.D.

INTRODUCTION

This paper reports on the second in a series of meetings on the

psychodynamics and psychotherapy of addiction (see Chapter 1).

These meetings represent a reawakening of interest in the psychological makup of addicts and in the perspective that psychoanalysis

can contribute to understanding and treating them. Addicts have

many different personality structures, and analysis, because it is a

special and unique way of getting information about personality,

may be able to add something to our understanding of addiction.

One might hope to develop a psychology of addiction based on

analytic insights. A possible result may be that certain abuse patterns

or personality types can be identified which will lead to modifications in treatment approaches. In addition, a subgroup of addicts

may be identified that will benefit from psychoanalytically oriented

psychotherapy.

This was a two-day meeting and contained both formal presentations and informal give-and-take discussions among all members,

addressing seven major areas:

• A review of the first meeting

• Priorities of this meeting

• Problem areas to consider in designing research involving

narcotic addicts

• Factors to be measured in psychodynamic-psychotherapy

studies with addicts

157
158 PSYCHODYNAMICS OF DRUG DEPENDENCE

• A proposed design for evaluating psychotherapy in drug abuse

treatment

• Other proposed studies

• Summary-future directions

This paper is a composite of contributions made by all participants and is designed to be understandable and interesting to

readers from analytic and nonanalytic backgrounds. Definitions of

analytic terms are included in the Appendix. The terms selected

include the major ones used in the meetings and are taken from A

Glossary of Psychoanalytic Terms and Concepts, edited by Burness

E. Moore, M.D., and Bernard D. Fine, M.D., published by the

American Psychoanalytic Association, second edition, 1968. The

discussions were often wide ranging, employing concepts from general psychiatry and addiction research as well as psychoanalysis.

Two main themes emerged from group discussions: (1) analytic

ideas relating to the understanding and treatment of addiction and

(2) research designs that can be developed to test these ideas. These

themes are common threads that run through each section of this

paper.

REVIEW OF THE INITIAL MEETING

The purpose of the first meeting, held on April 2 and 3, 1976,

was to reexamine analytic theory for its relevance to understanding

opiate addiction. It was the beginning of an attempt to develop

practical applications of analytic ideas in the field of drug addiction.

Participants shared a conviction that addiction needs a depth psychology and that analytic theory can be a useful tool in its development. Drs. Khantzian and Treece reviewed the discussion and

papers presented at this meeting (see Chapter 2). A summary

follows.

The early analytic views of addiction were based on libido theory.

They held that addiction resulted from libidinal fixation (notably

oral), with regression to that state of psychic development. The

need to explain the relationship between drug abuse, defenses, impulse control, affective disturbances, and adaptive mechanisms led

to the recent shift emphasizing ego psychology.

Participants agreed that serious ego pathology was often associated with drug abuse and most felt that this is indicative of profound developmental disturbances. Problems in the relationship

between the ego and affects emerged as a key area of difficulty,

including affective experiencing, control, intensity, and ambivalence.
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 159

The group members agreed that multi-modality treatment and

pluralism were sensible approaches to therapy and most felt that

psychotherapy can have a positive influence through its ability to

correct or improve ego defects. This view is consistent with Kohut’s

idea that drugs substitute for defects in ego development and that

long-term analytically oriented therapy can improve ego functions

and thereby reduce or eliminate drug abuse. Comments on the

techniques necessary for long-term therapy emphasized the importance of empathy and sensitivity to the addict’s fragile self-esteem

as well as the importance of walking a thin line between closeness

and distance. It was felt that a strictly transference-oriented approach should be modified and that the psychiatrist must play an

active role as well as be willing to use psychotropic drugs. Countertransference can be a major pitfall, and one adverse effect of

countertransference is that staff members will act out roles that

patients unconsciously seek.

In the discussion that followed the presentation of the review,

several members commented that analysis can both contribute to

and learn from the treatment of addiction. The group expressed an

interest in including addictive diseases in the curriculae of analytic

institutes, and panel members noted that they knew of only one

institute, the Boston Psychoanalytic, that includes courses dealing

with addiction.

Two major conclusions resulted from this first meeting:

• That addiction is often associated with serious ego pathology

• That long-term psychotherapy can reduce this ego pathology

and, thereby, lead to a better treatment outcome.

These conclusions are addressed later in this paper and serve as a

focus for the research design that resulted from this second meeting.

PRIORITIES OF THE SECOND MEETING

Early in the second meeting, held on March 17 and 18, 1977, the

group was asked by Dr. Pollin, Director of NIDA’s Division of

Research, to examine the ideas presented at the first meeting and to

distill and formulate them into testable hypotheses. As a first step

he asked the group for ideas that would help decide on the level of

approach to this task. Would it be best to focus on the issue of

heroin use, heroin abuse, or on some definable behavioral threshold

point that is part of an escalating pattern of drug consumption? Or,

to look at the problem in another way, to what extent should we

focus on heroin use rather than a more general “addictive state”?

The recent interest of NIDA to develop studies relating to nicotine
160 PSYCHODYNAMICS OF DRUG DEPENDENCE

abuse was mentioned in this regard. The group was not certain how

to answer these questions, and it searched in different directions

before reaching a conclusion.

First, several members presented analytic ideas relating to nicotine use. The theoretical contributions of Marcovitz (1969) and

Greenacre (1971) on the symbolic meaning of cigarette smoking

and inhalation were mentioned. Taking a lead from the issue of

nicotine use, studies by Jaffe (1975a) were mentioned that showed

similarities between the natural history of cigarette smoking and

heroin addiction. Other work by Jaffe (1975b) found evidence that

nicotine has the ability to reduce aggressive behavior. Using their

own experiences with drug abusers and this material, group members agreed that addictions probably share the following common

elements:

The use of a substance that produces a rapid and pleasurable

effect

Compulsiveness

Relating to the addictive drug as if it were an object relationship

• Biological changes resulting from drug use

• Cultural and genetic determinants

• Tendencies to be associated with antisocial behavior

Members added that there is a need to examine the factors that

prevent addiction as well as those that cause it. Several participants

commented that studies in this area may be more important than

those examining elements that lead to addiction. Studies of the

ego processes that operate in addicts, as well as studies that can

identify differences between the types of compulsions seen in

general psychiatry and those seen in addictions, were mentioned as

ways to investigate the personality factors that prevent addiction.

Though each of these areas was relevant to the question asked,

none produced a sense that the group had arrived at the area of high

priority for which it was looking. Members turned toward the

NIDA representatives for their thoughts on priorities. It became

clear that NIDA’s highest priority has been heroin addiction. This

judgment is based on estimates of health and social costs, which

indicate that heroin is the most burdensome drug problem from the

public health standpoint, followed by amphetamines, barbiturates,

hallucinogens, and marihuana, in that order. Alcohol abuse was

mentioned as an important area, and NIDA is now working with

NIAAA in developing cooperative research projects. Many group

members felt that tobacco may be one of the most serious of all

addictions from the public health standpoint. There was discussion about controlling tobacco smoking by prohibiting its growth
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 161

or sale, but it became evident that the complexity of the economic

issues involved in tobacco sale and production placed these issues

outside the scope of the technical review. The group left open the

question of the relative importance of tobacco versus heroin but

agreed that heroin addiction is an area of high priority.

The group retuned to the conclusion reached at the first meeting

-that addiction is often a result of severe ego pathology and that

psychotherapy can improve treatment effectiveness. This single

issue emerged as the highest priority research area. The group felt

that this is a necessary and realistic area to investigate. It is necessary because at this time there is little evidence besides clinical

impressions justifying the additional expenses resulting from inclusion of any type of intensive psychotherapy in the routine services

provided by narcotic treatment programs. It is realistic because the

effectiveness of psychotherapy can be tested using methods that

have been developed in other psychotherapy studies.

Other related issues were mentioned such as, if psychotherapy is

shown to help, what kind works best? How can addicts be classified?

Can psychoanalytic concepts be used to classify them? If classification is possible, can it help guide individuals into a type of therapy

that is most likely to give good results? Can the treatment program

milieu be modified, based on the psychodynamic understanding of

the addict, in order to improve the quality and efficacy of treatment? The group discussed practical benefits that could result from

studies that will provide answers. At this point, a priority area had

been chosen and the focus of the meeting turned toward issues

related to research designs.

PROBLEM AREAS TO CONSIDER IN DESIGNING

RESEARCH INVOLVING NARCOTIC ADDICTS

The first research area that the group discussed was the problem

of designing studies involving narcotic addicts. Some of these problem areas might be present in any research design, whether it deals

with addicts or nonaddicts. Most of the contributions to this part

of the discussion were made by members whose experience and

training were in research rather than by those experienced in

analysis.

Differentiating cause and effect was recognized as, at best, a

difficult process. There was discussion about this and questions

were raised regarding the pharmacological, cultural, and social impinging variables. Several participants felt that one difficulty in

doing research with addicts is in differentiating conditions that
162 PSYCHODYNAMICS OF DRUG DEPENDENCE

existed prior to addiction from those that result from cultural and

pharmacological effects acquired in the course of addiction. For

example, superego problems could be more a result of the laws

against heroin use than a condition for heroin addiction. Any study

of character pathology in addicts will have to deal with this problem. Longitudinal studies were proposed as the best way to separate

these variables, but they are expensive and difficult to design and

implement. However, it was argued that they would be of great help

in separating cause from effect.

An example of cause/effect problems in research is that studies

of ego structure in patients being treated with methadone will have

to control for any effects produced by methadone itself. It is not

known whether methadone changes personality structure, and it

was suggested that a nonmethadone treatment group should be used

for comparison.

A second area concerned the effects of non-treatment-related life

events on therapy outcome. For example, during the course of therapy, a patient may lose or get a job, become engaged or married,

move to a different neighborhood, experience the death of a close

relative, etc. These events may have a strong influence on outcome,

making it difficult to separate therapy effects from the sequelae of

life events. Keeping a record of such events that may occur during

the course of a study was suggested as a way of allowing them to be

taken into consideration when the data are analyzed. Another

suggested control for these variables was to do a collaborative study

with several clinics. This would increase the number of patients,

making it more likely that nontherapeutic interventions would wash

out in data analysis.

A third problem was the discontinuous nature of treatment that

most addicts experience. A typical addict is not in treatment continuously for longer than a year. Rather, he may be in therapy for

4 months, drop out, return 3 months later and then repeat this

pattern. Psychotherapy appointments may be erratic during each

treatment cycle. Carefully defining treatment, including length, is

one way to control this variable. Contingency payments can be

built into the treatment program to encourage patients to participate in their psychotherapy sessions.

A fourth area mentioned was that some patients in drug programs may be brain damaged or have low intelligence. The continuous use of high doses of sedative hypnotics, anoxia resulting from

drug overdose, and head injuries suffered in accidents were mentioned as events that produce brain damage in drug addicts. Dr.

Wurmser has studied this problem and found that 20 to 30 percent

of the patients in his program have minimal brain damage. Others
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 163

felt that the percentage is less than 20 to 30 percent, but all members agreed that organicity or subnormal intelligence may add

special difficulties with psychotherapy studies. The consensus was

that such patients should be screened out of research samples.

A fifth problem was the possibility of inaccurate conclusions

drawn by generalizing from the results of treatment done at only

one clinic. Clinics differ in personnel, treatment environment, and

policies, and these variables may influence outcome. A treatment

that works well at one clinic may not work at another. The group

felt that these differences are not easily controlled, but matching

clinics in a collaborative study would minimize them. Another

member raised the possibility that drug addicts in public treatment

programs may not be representative of addicts in general and that

the conclusions made from studies involving them may not be

generally applicable. The group felt that this problem could be

solved if patients from different socioeconomic and ethnic groups

were included in the study.

The final area dealt with problems that can result from arriving at

estimates of psychopathology by using historical material obtained

from patients. Several members had found that the reliability of

patient-obtained background information is inversely related to the

degree of psychiatric impairment. This will probably lower the

reliability of data that can be expected from addicts, because levels

of psychopathology are often high among the drug-abusing population. That measures of personality organization may be the most

reliable way to evaluate these patients psychiatrically was emphasized by those group members who have had the most analytic

experience. The emphasis on measuring personality structure was

repeated throughout this meeting and was a major contribution by

group members with analytic backgrounds and experience.

ELEMENTS TO MEASURE AND MEASURES TO BE USED

IN PSYCHOTHERAPY STUDIES WITH ADDICTS

The second research issue the group addressed was which background and diagnostic factors should be measured and how to measure them. The group arrived at an outline that was a composite of

input from members with analyticand general psychiatric perspectives.

All group members felt that demographic information such as

age, sex, race, occupation, marital status, education, employment,

criminal history, intelligence, type of neighborhood, and military

history should be included. Intelligence was singled out as especially
164 PSYCHODYNAMICS OF DRUG DEPENDENCE

important and several members indicated that it has been correlated

with outcome success in studies of both addicted and nonaddicted

psychiatric patients. Dr. Harriet Barr presented results from a study

recently completed by her colleague Dr. Arie Cohen (1977) that

show what can be done with demographic information. The study

included about 1,200 patients who were being treated in a therapeutic community and at methadone programs in the Philadelphia

area, Six typologies emerged :

• Type I included individuals who came from very deprived

backgrounds. These people had experienced real economic

problems. For example, they recalled periods during which

they went without essentials such as food or clothing due to

lack of money.

• Type II included those distinguished by their criminality, and

it included many professional criminals. People in this group

were found to use less narcotics than those in the other

groups, possibly because they exaggerated their drug problems in order to get favorable treatment within the criminal

justice system.

• Type III was a group with a history of problems in the parentchild area. These patients reported parental separations,

divorce, missing parents, histories of child abuse, and unhappy

childhoods.

• Type IV was a group with a history of psychiatric hospitalization, including suicide attempts.

• Type V consisted of people reporting behavior problems, such

as fighting in school, suspension from school, or hyperactivity.

• Type VI was a group who appeared normal and gave no history

of problems other than drug abuse.

Analysis of drug-use patterns in these groups showed significant differences, one being that cocaine was used more frequently by the

Type II addicts than by other groups.

All members felt that demographic typing such as this is important. The group commented on the importance of including data on

patterns of early trauma in demographic information. Dr. Krystal’s

work on the relationships between trauma, disturbances of affect,

and drug abuse was discussed in view of Dr. Barr’s report of a group

that is distinguished by parental abuse and other evidence of early

trauma.

Dr. Kemberg added that the extent of social pressure against a

particular drug of abuse is directly related to the severity of the psychopathology of individuals who become addicted to that drug. The

group suggested that estimates of social pressure should be included

in demographic information.
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 165

A second area that all members agreed should be included is the

patient’s abuse pattern. The group felt that this is important as a

basic piece of information and that it may correlate with other variables such as psychopathology, responses to treatment, age, sex,

race, occupation, or education.

A third area was physiological measures of addiction. Pupillary

dilation, skin temperature, skin resistance, stomach motility, heart

rate, respiration, and other psychophysiological indices can be

measured and correlated with subjective reports of narcotic withdrawal. Studies using these measures have shown that narcotic

withdrawal responses can be conditioned to occur in the presence

of various stimuli as well as in response to rapid detoxification or

administration of a narcotic antagonist. Addicts have been shown

to differ in the ease with which they acquire conditioned withdrawal

responses and in the number of stimuli that will produce them.

Measures of the intensity of physiological responses to withdrawal

and of patients’ susceptibility to conditioned withdrawal may serve

as indicators of outcome and guides for a treatment approach. For

example, someone who is easily conditioned may do better in a

program that places emphasis on deconditioning. It may be possible

to tailor each patient’s therapy to that class of agents that is particularly evocative for him or her. A subsequent reduction in conditioned withdrawal responses may be correlated with treatment

effectiveness.

A fourth area involved therapist variables and the therapeutic

process. The measures of accurate empathy, nonpossessive warmth,

and unconditional positive regard developed by Rogers and others

may correlate with outcome in addiction treatment (Rogers 1961,

Truax 1963, Rogers et al. 1967). Countertransference is also an

important variable and two scales were mentioned that can measure

it. Therapist charisma is another quality that may relate to outcome. Studies of therapeutic process were also mentioned, as was

Luborsky’s method that predicts outcome by listening to verbal

therapy segments. Videotapes could be made and used to study

these things as well as to document the kind of therapy actually

being done. But the group felt that therapy process studies should

be given a low priority due to the extensive methodological problems that researchers have found in trying to study it.

The fifth area the group felt must be included in any psychiatric

study is a psychiatric diagnostic study of the patients. This area

provoked much discussion because it is complex and involves two

general diagnostic levels: (1) the descriptive or general psychiatric

and (2) the underlying character or analytic. The descriptive level

is the easiest, as the measures suggested here are well known, widely
166 PSYCHODYNAMICS OF DRUG DEPENDENCE

used, and provide a systematic evaluation leading to a psychiatric

clinical diagnosis. The group showed a preference for including

clinical diagnoses as classified in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM). The group also

felt that measures of depression should be included, and the Hamilton and Beck scales were suggested. Other measures discussed were

the BPRS (Brief Psychiatric Rating Scale), MMPI (Minnesota Multiphasic Personality Inventory), the Rorschach, and the Psychiatric

Diagnostic Criteria developed at Washington University in St. Louis.

Dr. Kemberg suggested that something should be added to these

general psychiatric measures that will tap an underlying level of

psychopathology, namely, the underlying character structure. This

level has been relatively unexplored in addiction research, and it is

here that the insights developed through analytic work may be able

to broaden our understanding of addiction. He mentioned Luborsky’s Health-Sickness Rating scale and Gunderson’s scales for differentiating borderlines, psychotics, and neurotics as useful in

gaining insights to character structure and function. He also felt

that there are three areas of personality organization that are important to measure, and these are:

• The level of defensive functioning

• Identity diffusion

• Reality testing

He has been developing scales to measure these areas. They should

be complemented with special tests of personality features. These

scales may be of treatment and prognostic relevance. They include

quality of object relations as measured by stability, depth (including the ability to fall in love), superego measures, such as the extent

of a stable morality; evidence of selfdirected aggression; measures of

impulse control and anxiety expression; subliminatory potential;

severity of troublesome affects; intelligence; the wish to receive

therapy; capacity for meaningful emotional introspection; and likeability. Honesty, as opposed to sociopathy, was emphasized as

being of good prognostic value. In the course of the discussion that

followed, Weintraub and Aronson’s method for measuring defensiveness, Gottchalk’s method of using verbal segments to measure

anxiety and hostility, and the dependency-counterdependency scale

developed by Chodoff and NIMH were referred to and may be

useful.

Dr. Treece presented the results of a study she had completed

recently in which anxiety and impulsivity were measured in addicts

and nonaddicted controls. It involved four groups of subjects who

were confined to a women’s correctional institution: addicts, controlled nonaddicted users, experimenters, and nonusers. She found
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 167

that addicts were high on measures of anxiety and impulsivity,

whereas experimenters were low on anxiety and low on impulsivity.

Controlled users were more anxious than nonusers but were less impulsive. There was a small subgroup of polydrug users who had low

anxiety and high impulsivity scores. Nonusers were almost as

anxious as addicts, but they differed in having high rather than

low field dependency.

Several members commented that the study showed a way in

which relationships between anxiety, impulsivity, and cognitive

style can be tested experimentally. They felt that this kind of study

might serve as a model for using experimental methods to examine

relationships between analytic observations, ego functions, and drug

abuse.

Dr. Kemberg added that individuals often search for drug effects

that are specific to their personality organization. One personality

type is found in depressive-masochistic characters who have a sense

of destruction or loss of their internal world of object relations.

They want to overcome their emptiness with drugs and, at the same

time, achieve a sense of euphoria. Drugs for this group represent an

infusion of internal goodness, being loved, and loving. This group

has the best prognosis. The second personality type consists of

those who experience a fragmentation of self, of representations of

others, and of affects. These are often schizoid personalities who

attempt to use drugs to achieve a sense of organization (to obtain a

feeling of “being real” or “being put together again”). The third

type, resembling narcissistic personalities, are those who use drugs

to replace people or to restore a sense of loss of control over the

environment. Drugs permit them a sense of grandiose control of the

environment, thereby helping to maintain a sense of superiority.

This last group may be very difficult to treat, especially since there

is a subgroup with paranoid features.

After pausing and reflecting on the complexity of this entire

area, the group concluded that the best approach is a multidimensional one. A study should select the most appropriate and practical

measures in each area. Dr. Klerman discussed his positive experiences using this approach in psychotherapy drug studies and pointed

out similarities between work done elsewhere and the proposal

being discussed here.

Dr. O’Brien and Dr. Pollin suggested that the field would be

enhanced by developing a composite instrument that would specifically measure addiction severity. This scale would provide uniformity and standardization in measuring severity of addiction and

would be useful in evaluating changes resulting from treatment as

well as in comparing patients from different treatment programs.
168 PSYCHODYNAMICS OF DRUG DEPENDENCE

The focus of the meeting now turned to considerations dealing

with a design that can be used for a psychotherapy study.

PROPOSED DESIGN FOR A PSYCHOTHERAPY STUDY

One of the main purposes of the meeting was to formulate research designs and this session dealt with specific proposals. Several

were discussed but no single one was selected as the final product.

The first step was to determine which treatments should be studied.

Three kinds were proposed: supportive, analytic, and a combination

of the two. The group agreed that supportive therapy should be

included. (See Appendix for a definition of “supportive therapy”).

Several members focused on problems that can be anticipated in

doing analytic psychotherapy with addicts. One had to do with

addicts’ efforts to manipulate therapy to fit their needs for control,

support, or gratification. Other problems were the addicts’ difficulties in keeping regular appointments, their tendency to externalize

problems, and their pattern of dealing with problems in a way that

does not reflect high levels of psychological awareness. Using group

analytic rather than one-to-one therapy was suggested as a solution,

but several members mentioned that they had tried analytically

oriented group therapy and experienced attendance problems.

Dr. Khantzian recalled that he had solved attendance problems that

were occurring in his program by making group therapy mandatory.

Other difficulties were mentioned, and the members concluded that

group therapy may present too many problems to be used in a

psychotherapy study and indicated a Preference for one-to-one

therapy.

The problems inherent in doing analytic psychotherapy with

addicts led to suggestions by several members that the study use a

therapy that combines supportive and analytic treatments. The

group felt that this probably would result in neither good supportive nor good analytic treatment, and they chose to use the

purer types. Members suggested that an ongoing monitoring system

(videotapes) should be included in the study to provide a means of

quality control. This would document what kind of therapy is

actually being done. If the therapy is different from that called for

in the research design, the tapes will help determine whether this is

due to qualities belonging to the therapist or the patient and also

will provide a means for maintaining a consistent type of therapy

through supervision. There was general agreement that analysis

per se is unpractical, but the possibility of testing it on a selected

group was not ruled out.
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 169

The second step was to decide if psychotherapy should be tested

alone or in combination with methadone. Some members proposed

a study that would include patients who are treated with only

analytic or supportive therapy and not with methadone. Several

members discussed their negative experiences in trying to treat

addicts without methadone and emphasized how they had been

impressed by methadone’s ability to stabilize addicts and involve

them in therapy. The NIDA staff members reminded the group that

studies of drug-free therapy are appropriate because the majority

of addicts in treatment in the United States are in drug-free modalities. Some discussion followed about the kinds of addicts that can

be expected to continue in drug-free treatment, and the group concluded that psychotherapy alone will not keep heroin addicts in

outpatient treatment unless special circumstances are operating,

such as legal pressures or involvement with a therapeutic community. The members concluded that the value of methadone has

been established in outpatient programs and the highest priority of

the study is to see if psychotherapy improves methadone treatment.

The value of selecting the best (those patients judged most likely

to benefit) and the worst cases versus selection of only the best was

discussed. The group felt that much can be learned by studying

patients with the worst prognosis, but several members pointed out

that including the worst cases may mask positive results and that

this could lead to termination of research support for future projects. The group concluded that it is preferable to study the best

group first and to include poorer prognosis patients at. a later time

if positive results are found in the first study. Several members also

felt that it is important to design studies with an eye to identifying

who needs psychotherapy and who does not. Robins’ study of

Vietnam veterans was mentioned as having demonstrated that there

are many addicts who do not need formal therapy in order to discontinue their addiction to heroin. The group felt that careful diagnosis may be fundamental in deciding on appropriate treatment.

For example, analytic psychotherapy may benefit an addict with

depression but not one with psychopathy.

These comments led to one basic design: randomly assign outpatients to methadone alone, methadone plus analytic therapy, and

methadone plus supportive therapy. Variants of this design involved

including drug-free groups and/or both good and poor prognosis

patients in the random assignment, but this was not preferred.

The group added that it may be more difficult to do this study

than it appears. Matching therapists, defining treatment, defining

patient groups, guaranteeing quality control, matching clinics, controlling for length of treatment, controlling for life events, and
170 PSYCHODYNAMICS OF DRUG DEPENDENCE

providing large enough numbers of patients are some areas that

need clear definition in formulating an experimental design. Three

years was estimated as a reasonable duration for the study, and

most members felt that a collaborative effort is better than one in

which separate studies are done in different clinics. This will allow

larger numbers of patients to be studied, thereby providing more

control and increasing the significance of the results.

OTHER PROPOSED STUDIES

The discussions also generated ideas for other studies dealing

with pharmacology, longitudinal development, therapy variables,

and cultural factors related to drug abuse. Several studies were proposed to investigate the pharmacological properties of drugs used in

treatment. One involved examining the common elements shared

by addicting substances and relating them to pharmacological factors of drugs used in treatment. Several group members felt that

the rapidly acting drugs are the most useful and singled out the

mood-elevating drugs with long latencies for study. Another proposal was to examine whether the slow onset of action of the

mood-elevating properties of LAAM is related to difficulties seen in

stablizing addicts on this drug.

Issues dealing with longitudinal developmental processes generated considerable interest, but the group was aware that they may

not be economically feasible. However, leaving economics aside,

many possibilities were suggested and they included three areas.

First was to design a study that would answer the question, raised

in earlier discussions, of whether drug abuse is progressive or regressive. In other words, does it lead to improvement or deterioration

of personality function? Stages in the development of drug abuse

or identification of drug abuse patterns may be important to identify here, because there may be some patterns that will lead to one

result rather than the other. An especially important developmental

step is the phenomenon of “losing control.” This is a focal point in

the progression from drug use to addiction. An extension of earlier

studies done by Zinberg (1975) on people who use drugs continuously but irregularly and are not addicted (“chippers”) may be able

to identify personality elements that act as counterweights against

the progression from use to addiction. Measuring ego functions in

nonaddicted siblings and further development of the work started

by Milkman and Frosch (see Chapter 10) on defensive style and

drug of choice may be helpful. The group added that developmental
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 171

studies involving relationships between personality and addiction

would provide a good starting point to verify the observation that

the reasons individuals become addicted are often different from

those that perpetuate the addiction. Longitudinal studies could also

examine the relationship between trauma, affects, impulse control,

and drug abuse, a syndrome suggested as commonly associated with

the subsequent development of addiction.

A second developmental area is whether aggressive behavior and

psychopathy precede addiction. A study was mentioned demonstrating that children who have a history of fighting are more likely

to become addicts than peers who are more peaceful. Other studies

have shown that criminal behavior, as measured by arrest records,

precedes heroin addiction. However, the data in these studies are

often contaminated, partly because heroin addiction is often the

end point in a pattern of polydrug abuse and these drug abuse

patterns may contribute to the criminal behavior.

A third area dealt with studies relating to maternal care functions

and addiction. It may be possible to identify certain behaviors, attitudes, or interactional patterns that are likely to be associated with

the subsequent development of addiction. Children of addicts may

have an increased chance of becoming addicted, and physiological

changes found to occur in children born to alcoholic mothers may

be found in adolescents who become alcoholics. Studies in this area

may build on research that is already in progress.

The main proposals dealing with therapy were discussed and presented earlier. One further proposal was to try to identify those

people for whom total abstinence is appropriate and to determine

what differentiates them from those who should be on continuous

methadone maintenance.

The last area for study was the cultural. The group felt that a

study which could identify the social and cultural features that encouraged or discourage drug abuse and addiction will be of great

value. Robins’ study of Vietnam addicts was mentioned in this

regard. Studies of the cultural determinants of use and abuse of

diazepam were mentioned as another area of interest, as well as the

relationship of psychiatric problems to race. One member’s data

showed that black addicts have high levels of psychopathology,

whereas data presented by others show that it is low. These differences may result from the measures used to determine psychopathology in the studies: APA DSM II criteria were used by some members, and measures of drive states and ego functions were used by

others. Further studies in this area are of interest and importance,

especially as they may provide data on whether psychopathology

necessarily accompanies drug dependence.
172 PSYCHODYNAMICS OF DRUG DEPENDENCE

SUMMARY-FUTURE DIRECTIONS

Several important conclusions came from this meeting. First, it

was agreed that analytic theory has a contribution to make to the

understanding of the nature and treatment of drug addiction. The

group decided that the highest research priority is a comparative

psychotherapy study done on heroin addicts in outpatient methadone treatment. This will include matched patients who are randomly assigned to psychoanalytically oriented, supportive, and

no-therapy (methadone only) groups. Poor prognosis patients are

to be excluded, as are patients with signs or symptoms of organic

brain damage. The study should be a collaborative one and will

take about 3 years. Efforts should be made to match the clinics

that participate, though this is acknowledged to be difficult.

Measures taken will include the demographic information mentioned earlier and should measure the amount and magnitude of

early trauma. Drug abuse patterns should be noted and urine tests

results, arrest and employment records are to be recorded at regular

intervals. Patients will undergo psychiatric diagnostic studies at

intake and throughout the study. They should include general

diagnostic tests as well as measures of personality structure appropriate to psychoanalytic classifications of ego pathology. An APA

DSM II diagnosis, the Hamilton and Beck measures of depression,

and measures of affect expression versus constriction are the preferable general measures. Luborsky’s health-sickness rating scale and

special tests measuring level of defensive functions, quality of object relations, and accuracy of reality testing are the most important

areas of personality function and ego structure.

Physiologic recordings of narcotic withdrawal response to naloxone injections and responses to stimuli that produce conditioned

withdrawal responses may also be included. These measures can

only be done on a few patients in selected clinics since they are very

time consuming and since most clinics do not have the equipment

necessary to do them.

Measures of therapist variables, such as those developed by

Rogers et al., and countertransference should be included. Therapy

sessions should be taped (video or audio) to document the kind of

therapy actually being done. Therapeutic process notes or tapes can

be included, but, like physiologic measures, studies of therapy process are lengthy and can only be done on a few selected patients.

Another meeting is planned for later this year, and the group

consensus was that psychometricians, biostatisticians, and research

psychologists should be included, with the aim of further operationalizing clinical concepts and observations into instruments and
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 173

techniques to be used in experimental studies. Dr. Pollin expressed

his strong interest in developing research in this area and his thanks

to all the participants.

APPENDIX: DESCRIPTIVE AND THERAPEUTIC TERMS

I. Descriptive Terms

Ego: The ego occupies a position between the primal instincts,

based on the physiological needs of the body, and the demands of

the outer world. It serves to mediate between the individual and

external reality. In so doing, it performs the important function of

perceiving the needs of the self, physical and psychic, and the qualities and attitude of the environment. It evaluates, coordinates, and

integrates these perceptions so that internal demands can be adjusted to external requirements. In so doing, it sometimes brings

relief from drive tensions by a reduction in the intensity of the

drives (taming) or by a modification of the external situation. While

doing this, it strives to maintain good relations with the external

world and with the superego.

Ego Functions: The means used by the ego in performing its duties.

These involve:

• Reality Testing-This is often distorted in neuroses and is very

disturbed in psychoses.

• Regulation and Control of Drives-This function is measured

by the ability to tolerate anxiety and depression and to delay

satisfactions.

• Object Relations-This involves the ability to form affectionate, friendly ties to other individuals and to have the ability

to maintain them.

• Thought Processes-The ability to perceive what is going on

and to coordinate, classify, and make sense of perceptions,

i.e., to “think.”

• Defensive functions-Methods used by the ego to protect itself from danger. See “Defenses.”

• Autonomous Functions-These include perception, motility,

intention, intelligence, speech, and language. These are less

frequently affected by emotional disturbances than other ego

functions.

• The Synthetic or Organizing Function-This is the capacity of

the ego to unite or organize the drives, tendencies, and functions within the personality in order to enable the person to

feel, think, and act in an organized and directed manner.
174 PSYCHODYNAMICS OF DRUG DEPENDENCE

Defenses: The means available to the ego to protect itself from

danger. The integrity of the ego is sometimes threatened by the

potential eruption into consciousness of an impulse or wish that has

been associated with some real or imagined punishment. This is

signaled by feelings of anxiety or guilt that then impel the ego to

ward off the wish or drive. Defenses always operate unconsciously

so that the person is unaware of what is taking place. The specific

methods used are known as defense mechanisms, and these include

sublimation, repression, displacement, reaction formation, projection, isolation, and undoing. The operation of such mechanisms

may result in a deletion or distortion of some aspect of reality.

Being defensive is a general term used to describe a situation in

which the ego is struggling to protect itself from danger. Some defenses are indicative of mature ego functioning (sublimation) and

others of a more primitive ego (projection).

Ego Defect: Impairment in one or more ego functions.

Superego: The internal representative of the standards of behavior

and moral demands imposed from without.

Libido: A concept that refers to a measure of the drive energy of

the sexual (pleasurable) instinct, but not denoting sexual appetite

or conscious sexual desire. It is one great dynamic force that gives

rise to conflict in the course of mental development. The other

forces are the self-preservative and aggressive drives. It can be invested in the intrapsychic representation of objects (object libido)

or the self (narcissism).

Libido Theory: The theoretical description of a biological maturational sequence of pleasurable phases starting with the oral and ending with the genital phase. The theory assumes that the sources of

the sexual instinct are derived from somatic processes that are psychologically experienced as impulses. There are component drives

usually associated with specific erogenous zones and wishes or fantasies (a mental organization) representative of each phase. The drive

organization is subject to progressions, regressions, and fixation.

Regression: A retreat to an earlier phase of instinctual (libidinal) or

mental (ego) organization. Libidinal and ego regression not infrequently occur together. Regression occurs if the individual is presented with difficulties he is unable to master. The extent and form

of regression are often determined by unresolved conflicts and

anxieties at earlier phases that leave areas of weakness (fixations)

to which the individual is likely to regress. For example, at times of

stress, a 5-year-old child resumes thumb-sucking (libidinal regression); or, when experiencing difficulty in finding a job, a young

man gives up, starts overeating, and wants to be “taken care of”

(ego and libidinal regression).
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 175

Adaptation: The capacity to cope reasonably yet advantageously

with the environment. Successful adaptation provides a gratifying,

satisfactory discharge of instinctual forces within the limitations

imposed by the external world without pathological alteration of

the ego. It requires conforming to reality but does not preclude

activity directed toward its change. Adaptation is accomplished by

active efforts of the ego, and successful adaptation is regarded as

one criterion of healthy ego functioning.

Fixation: The tendency for residuals of earlier libidinal, ego, or

superego phases to acquire and retain strong “charges” of psychic

energy and to play a significant role in later mental functioning.

These then permit the persistence of primitive ways of satisfaction,

of relating to people, and of reacting to old dangers.

Narcissism: A concentration of psychological interest upon the self.

Normally, an individual’s interests are divided between self-concern

and concern for the world of things and people around him (object

love). Painful self-consciousness and an increased propensity for

shame are the outcome of conflicts over narcissism. Exaggerated

narcissism may be associated with ego regression and difficulty in

object relations.

Object Relations: Personal interactions that include both direct

instinctual gratification (sexual, aggressive) as well as instances

where gratification is sublimated, as occurs in friendships and in

love between parent and child. Primitive object relations are characterized by a relative inability to maintain a love relationship and

to accept the limitations and separateness of the loved object. A

mixture of love and hate, known as ambivalence, is characteristic

of impaired object relationships.

Object Representation: An enduring schema of a particular person

modeled by the ego from experiences with that person. Object

representation comes to exist independent of real satisfaction. For

example, after the object representation of mother is formed, the

child perceives her as the same person even when he does not need

her to feed or wash him.

Self-Representation: A more enduring schema than the self-image

and constructed by the ego out of the multitude of realistic and

distorted self-images that the individual has had at different times.

It represents the person as he consciously and unconsciously perceives himself. It includes enduring representations of all the

experienced body states and all the experienced drives and affects

that the individual has consciously or unconsciously perceived in

himself at different times in reaction to himself and to the outer

world. Together with the object representations, it provides the

material for all the ego’s adaptive and defensive functions.
176 PSYCHODYNAMICS OF DRUG DEPENDENCE

Ambiualence: The simultaneous existence of opposite feelings,

attitudes, and tendencies directed toward another person, thing, or

situation. Ambivalence is universal and not necessarily pathological

because there are few affectionate relations that are uncomplicated

by hostility, and many hostile relations are tempered by affection.

However, when the strength of these conflicting feelings increases

to the point where action seems unavoidable yet unccceptable,

defensive measures and mental disturbance often result.

II. Therapeutic Terms

Transference: The displacement of patterns of feelings and behavior,

originally experienced with significant figures of one’s childhood, to

individuals in one’s current relationships. This process is unconscious and brings about a repetition of attitudes, fantasies, and

emotions. The parents are usually the original figures from whom

such patterns are displaced, but siblings, grandparents, childhood

teachers, and doctors may be contributing figures. Transference

may develop in any human relationship. It is of major significance

in the analytic process. The demonstration, interpretation, and

resolution of transference in the analytic situation constitute the

core of analytic therapy. Transference may involve predominately

friendly, affectionate, or sexual feelings (positive transference) or

mainly aggressive, hostile, or even sadistic wishes (negative transference). A strong working relationship between the patient and therapist is essential to the continuation of analysis, especially during

periods of strong negative transference.

Counter-transference: Refers to the attitudes and feelings, only

partly conscious, of the analyst toward the patient. These may

reflect the analyst’s own unconscious conflicts and, if he is not constantly aware of this, may affect his understanding and therapeutic

handling of the patient. In countertransference, the analyst has displaced onto the patient attitudes and feelings derived from earlier

situations in his own life; the process is analogous to transference

that involves the patient’s similar reactions to the analyst. One of

the cardinal purposes of the analyst’s own analysis during his training is to make him aware of his own conflicts and their derivatives

so that they do not distort his therapeutic work with patients. The

analyst’s continuing scrutiny of his own countertransference feelings frequently provides correct clues to the meaning of the patient’s

behavior, feelings, and thoughts and may facilitate more prompt

perception of the patient’s unconscious.
WOODY: DIAGNOSTIC AND THERAPEUTIC ISSUES 177

Interpretation: A form of intervention by the analyst, whose aim is

to achieve therapeutic results by adding to the patient’s knowledge

of himself through making him aware of psychic content. In general,

interpretations are dynamic or genetic in nature. Dynamic interpretations refer to psychic forces operating to produce a particular

effect on mental life at any given time. Genetic interpretations are

concerned with indicating or clarifying the connections between

past mental states and present ones.

Insight: The subjective experiential knowledge acquired during psychoanalysis of previously unconscious pathogenic content and conflict. Analytic insight differs from other cognitive understanding in

that it cannot occur without being preceded by dynamic changes

leading to the weakening of resistances and the release of energies.

These augment the autonomous ego functions that make insight

possible. Among the more important autonomous ego functions

involved are self-observation, synthesis, perception, memory and

reality testing, control over regression and affective discharge, and

integration.

Pseudo-insight may occur, in which there is apparent intellectual

understanding of the forces involved, but instead of an integrative,

energy-releasing function, the knowledge serves a libidinal or aggressive purpose with respect to the analyst, e.g., to please, to deceive,

or to defeat him.

Supportive Therapy: Treatment in which the therapist intervenes

directly in order to reintegrate the patient’s impaired ego. This contrasts with analytic therapy, in which the therapist and patient

work together, using the analysis of transference, in order to help

the patient to diminish and control his neurotic reactions. Supportive therapy may include the use of psychoactive drugs, direct encouragement, expressions of positive regard by the therapist, or

discussions of transference distortions in the context of present

reality. For example, “You feel that I am against you but I am not.

This clinic has suspended you because you broke the rules; we are

not against you. These same rules apply to everyone being treated

here.”

Analytic Therapy: A form of treatment where past feelings, forbidden wishes, and the defenses associated with them are experienced

in the interpersonal situation that develops between the patient and

the therapist and in which these feelings are related to earlier life

events. This expression of feelings, wishes, and defenses in the therpeutic situation is called the transference, and the process by which

they are related to earlier life events is known as interpretation. The

essence of analytic therapy is the patient’s achievement of greater

insight leading to mastery and progressive maturity of his affective
178 PSYCHODYNAMICS OF DRUG DEPENDENCE

responses through their subjective experience in the transference

and its interpretation. In this way, analytic therapy can help the

patient separate feelings appropriate to current life events from responses that are related to other processes. This can lead to a lessening of symptoms and an enrichment of the total personality.

Analytic therapy is a long and difficult process because many of the

past feelings are unconscious and the patient often resists their expression and analysis. Successful analytic therapy requires that the

patient simultaneously experience and observe his responses while,

at the same time, collaborating with the analyst in the interpretive

work. The development and interpretation of the transference distinguishes analytic from supportive therapy. Analytic therapy

is usually used for neuroses but has been applied to borderline conditions and other, more serious disorders.

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The following bibliography was compiled by computer search, as

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180 PSYCHODYNAMICS OF DRUG DEPENDENCE

Dole, V.P., and Nyswander, M.E. A medical treatment for diacetylmorphine (heroin) addiction. Journal of the American Medical

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BIBLIOGRAPHY 181

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182 PSYCHODYNAMICS OF DRUG DEPENDENCE

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CONTRIBUTORS

Jack D. Blaine, M.D.

Division of Research, NIDA

11400 Rockville Pike

Rockville, Maryland 20852

Virginia Davidson, M.D.

Department of Psychiatry

Baylor College of Medicine

Houston, Texas 77019

William A. Frosch, M.D.

Department of Psychiatry

Cornell University Medical Center

525 East 68th Street

New York, New York 10021

Stanley I. Greenspan, M.D.

Mental Health Study Center

Division of Mental Health Service

Programs

National Institute of Mental Health

2340 University Boulevard

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Demetrios A. Julius, M.D.

Division of Research, NIDA

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Eugene H. Kaplan, M.D.

25 Chapel Place

Great Neck, New York 11021

Edward J. Khantzian, M.D.

The Cambridge Hospital

Department of Psychiatry

Harvard Medical School

1493 Cambridge Street

Cambridge, Massachusetts 02139

Henry Krystal, M.D.

Department of Psychiatry

Michigan State University

East Fee Hall

East Lansing, Michigan 48824

Harvey Milkman, Ph.D.

Drug/Alcohol Counselor Training

Program

Metropolitan State College

250 West 14th Avenue

Denver, Colorado 80204

Catherine J. Treece, Ph.D.

Cambridge Hospital

Narcotic Treatment Program

485 Massachusetts Avenue

Cambridge, Massachusetts 02139

Herbert Wieder, M.D.

25 Chapel Place

Great Neck, New York 11021

George E. Woody, M.D.

Drug Dependence Treatment

Service

Veterans Administration Hospital

38th Street and Woodland Avenue

Philadelphia, Pennsylvania 19104

Leon Wurmser, M.D.

University of Maryland School of

Medicine

Division of Alcohol and Drug

Abuse

721 West Redwood Street

Baltimore, Maryland 21201

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