Introduction - Addiction: A Ubiquitous Problem

The scope of the problem

The editors of this section wished to explore psychoanalytic approaches to addiction and substance abuse; though not sub-specializing in that domain, in our own practices, we found we were both treating several patients with opiate, alcohol, and marijuana dependence.

As of 2014, one in four young adults aged 18–25 reported misuse of prescription or illicit substances, which include marijuana, stimulants, and heroin. The National Survey on Drug Use and Health (NSDUH) is a nationwide survey of 70,000 people aged 12 and older on tobacco, alcohol, and drug use and mental health in the United States. It has been conducted yearly since 1971. Results from the most recent survey, in 2019, give us cause for both hope and concern. Opiate use has diminished, now affecting about 2 million people. Marijuana was the most frequently used illicit substance, and its use is increasing; 17% of those over 12 years old had used it in the past year. In youth 12 to 25 years old, marijuana smoking is associated with depression and concurrent opioid and alcohol abuse.

The public health dimension: little and limited treatment

Adolescents and adults with substance use disorders rarely receive treatment. Approximately 20 million people in the United States have substance abuse disorders and 9 million have co-occurring mental illness and substance disorders; less than 1 in 10 in either of those groups obtain treatment. Most substance abusers have problems with alcohol, with or without the addition of other drugs.

According to one recent review, a third of adolescents with a substance use disorder also had a co-occurring mental illness (Robinson and Riggs 2016). This finding seems less than clinical experience would suggest. Among adolescents referred for treatment psychiatric co-morbidity was higher, with diagnoses of: conduct disorder (60–80%); attention deficit hyperactivity disorder (ADHD; 30–50%); and major depressive disorder (MDD; 24–50%). Substance abuse and psychological disorders may co-occur, lead to one another, and/or exacerbate each other.

To recap, only a small fraction of substance abusers, about 5%, identify themselves as having a problem and seek treatment (Smith and Borden 2020). Among those who seek treatment, few receive it from a practitioner with mental health training of any kind. Substance abuse counselors by and large are not trained in child and adolescent development which is important, given that the most common age range for diagnosis of substance disorders is young adulthood; neither are substance abuse counselors generally familiar with the treatment of psychological disorders other than substance abuse. There is a shortage of practitioners trained to treat both substance and psychological disorders, though many believe integrated treatment, e.g., treatment that addresses psychological, psychiatric, and substance problems, is necessary. (Robinson and Riggs 2016).

Legislation passed during the Obama administration provides a ray of hope in this situation. The Affordable Care Act (Patient Protection and Affordable Care Act 2010) has provided almost universal coverage and the Mental Health Parity and Addiction Equity Act (Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 2008) mandates parity of treatment for substance abuse disorders with other medical disorders (McLellan and Woodworth 2014). These acts destigmatize addiction by recognizing it as an illness and requiring coverage by medical insurance (Woodworth and McLellan 2016).

The role of psychoanalysts

Most child and adult psychoanalysts will encounter patients with substance abuse or dependence in their practices, and a significant number will also treat patients with those problems. In one recent survey of psychodynamic psychiatrists, over half treated some patients with substance dependence (Alfonso and Olarte 2011).

There is a dearth of practitioners trained both to treat adolescents and young adults, and substance misuse and dependence. Substance dependence is a challenge to current treatments, with reviews of outcome showing a success rate of only about 50%. That level of outcome, however, is the same as for treatment of other chronic illnesses, such as asthma, hypertension, and diabetes (Volkow 2011).

A current trend in mental health is that treatment be “evidence based.” There are relatively few case reports of treatment of substance dependence in psychoanalysis, and even fewer studies of psychoanalytically oriented treatment of substance dependence. Psychodynamic psychotherapy and psychoanalysis are not included in current reviews of recommended treatments for adolescents, young adults, or adults with substance dependence and psychiatric disorders (Brewer, Godley, and Hulvershorn 2017; Hinckley and Riggs 2019). As most who follow treatment research know, efficacy trials provide only one specific context for observation and they are not necessarily the royal road to the truth (Moos 2003). Just to cite one difficulty with research treatments, manualized psychotherapies are almost always brief, often less than three months in duration. Practitioners who treat patients with moderate to severe difficulties know that prolonged treatment is usually necessary. The duration and continuity of care are particularly important in the treatment of substance abuse disorders (Moos 2003). Psychoanalysts, because of their familiarity with treatment in depth, taking place over years may therefore have an advantage in treating such patients. Because ongoing treatment is often necessary, many have suggested that severe substance abuse disorders be treated as chronic illnesses (McLellan et al. 2014; Fonagy et al. 2014; Saitz et al. 2008).

We wondered how psychoanalysts who are expert in this area conceptualized treatment of such problems; how they understood the dynamics of addiction–whether there even were universal dynamics, how they approached the difficult transference and countertransference issues that arose, whether they referred patients for concurrent, specialized outpatient or inpatient addiction treatments, and how they involved parents of adolescents in their work. How did psychoanalysts employ parameters such as helping patients to anticipate negative consequences of substance abuse, while remaining neutral in spirit? How did they handle the difficulty of achieving complete, or even partial success with addicted patients? How do psychoanalysts understand residential treatment, including the recent phenomenon of sending substance-abusing adolescents to wilderness programs?

Prevention

Child clinicians can be instrumental in prevention of substance abuse by promoting warm and nurturing parenting, recommending treatment of parental substance abuse and treating children’s social, learning, and developmental difficulties – all conditions which are implicated in the prevention of early-onset and later substance abuse (Kaplow, Curran, and Dodge 2002). At the early stages of life, promotion of secure attachment is important in ongoing protection of adolescents from harmful misuse of substances (Schindler and Bröning 2015). At a societal level, shielding children from economic deprivation, exposure to environments where drugs and alcohol are common, and encouraging children’s school and community involvement all hold promise of reducing the incidence of later substance dependence (Harrop and Catalano 2016). Treatment of ADHD, anxiety and depression, remediation of learning disorders, and improving social functioning could also be expected to prevent the misuse of substances later (Biederman et al. 1995).

Children affected by a parent’s substance dependence are especially at risk and need our educated attention. As of 2014, about 1 in 8 children lived with a parent who was dependent on a substance, most often alcohol (Lipari and Van Horn 2017). There is an excellent recent review of how parenting is affected by substance abuse (Barrocas, Vieira-Santos, and Paixão 2016) but very little has been written about how to help children in mourn the partial or complete loss of the substance-dependent parent.

Mary Brady has written a thoughtful exploration of this topic for our section. She describes work with children of alcoholics, in which she facilitates the children’s ability to symbolize their worries about their afflicted parents through play. Fostering verbal expression of what the children observe about their parents helps children understand the parent’s difficulty at their developmental level. Brady discusses the chronic mourning that occurs in families in which there is ongoing substance dependence by a parent. She also delineates the resulting anxiety and inhibitions in the children of alcoholics. Significantly, Dr. Brady gives us a detailed account of her work with both the affected and with the unaffected, “co-dependent” parent. This account will be highly useful to any practitioner who works with families in which a parent is substance-dependent.

Psychopathology

Addictive disorders are multiply determined, meaning that no single theory of etiology can account for their development. Edith Sabshin (1995) reviewed psychoanalytic writings on the topic until the 1990s, including the significance of oral erotism (Glover), environmental deprivation (Winnicott, Balint), narcissistic injury (Kohut), a tormenting superego (Wurmser) and defenses against aggression, dependency needs and depressive affect (Blatt). Another review, by Johnson posits an addictive character style that is marked by the use of denial and intoxication as defenses against various problems and affects (Johnson 2003).

Though many have related substance dependence to preexisting psychopathology, a counterargument that psychopathology is not the decisive factor is found in the longitudinal study of alcoholism in Harvard and town men: bleak childhoods and child psychological problems did not differentiate those who became alcoholics from those who became social drinkers (Waldinger 2002). The importance of early history continues to occupy psychoanalytic authors on addiction, nonetheless. Only prospective studies can illuminate what are probably multiple trajectories that end in addiction.

Some psychopathology develops because of the psychophysiological addictive process. This led George Vaillant to remark that there were many alcoholics who were perfectly good husbands and employees when they were sober, showing little of the immature and problematic behavior that they evidenced when drinking.

A relatively new way of looking at the addictive process for alcohol and other drugs is George Koob’s concept of “hedonic homeostasis.” Feelings of pleasure arise when the hedonic threshold is crossed, but the hedonic threshold is raised with chronic drug use. Ordinary pleasures can feel empty by comparison to the feelings induced by drugs of abuse. Because the hedonic threshold has been raised, the addicted person can experience ongoing dysphoria that is only relieved by drug abuse (Wise and Koob 2014). In other words, the “highs” of drug use leads to chronic dysphoria between administrations of the drug. The drug mis-user only recognizes the relief afforded by the drug, and then is drawn into repeated, compulsive use of the substance (McCauley 2010).

Sweet (2013) comments that descriptions of work with addicted patients frequently include early disturbances of attachment, complex transferences involving dependency needs, primitive defenses, and comorbid psychiatric conditions, especially personality disorders, ADD, and learning disabilities. He goes on to say: “Most writers would agree that addiction to substances develops in the context of attempts to anesthetically freeze a severely troubled and troubling inner world. They would, I think, also recognize the vicious cycle that is created by an increased physical tolerance to the psychoactive effects of substances leading to deteriorating psychological capacities.”

In our experience, we have also been struck by the mistrust, denial, avoidance, and desperation in patients with addiction. Patients with addiction often have history of trauma and depression, and both are often multi-generational (Miller 1994).

José Zusman gives us a new way of thinking about addiction, namely, that it develops due to an early environment in which healthy dependence is not possible, or when healthy dependence is disrupted later in life. In Zusman’s formulation, the axis of addiction is a narcissistic retreat:

In the event of a trauma that interrupts our progression along the axis of dependence, we are forced to turn towards the axis of addiction, like a turtle that protects itself by withdrawing into its shell. When this occurs, we become imprisoned, temporarily or permanently, in our most infantile state …

Dr. Zusman describes the treatments of two patients with addiction. In both, he conveys the frustration, boredom, and feelings of abandonment he experiences in the countertransference, as he resonates with the patients’ experiences of withdrawal from human engagement. Zusman fosters his patients’ self-reflection, awareness of their pain and vulnerability, and ultimately their engagement with him.

Joanna Bettman and her colleagues, Gabrielle Kouris, Ileana Anderson, and Bryan Casselman wrote for our section about the use of psychoanalytic concepts in a wilderness program. In so doing, this group helpfully summarizes the thoughts of three seminal psychoanalytic writers on addiction: Khantzian, Dodes, and Wurmser. Much of the work of these writers has entered the discourse on addiction in the mental health sphere, including Khantzian’s self-medication hypothesis, his emphasis on the caring and respectful attitude of the clinician, and his objective of increasing affect tolerance. Dodes’ contributions include the idea of substance use as a compulsive defense against narcissistic injury and helplessness. Wurmser focuses on the intense feelings of shame and worthlessness in those with substance abuse disorders.

Dr. Bettman makes use of these concepts in treatments for adolescents in wilderness programs. In one of Dr. Bettman’s cases, she expresses the feeling of being shut out that is often described in working with patients who abuse substances. In another, she describes the rewarding development of an alliance with a young woman with significant shame.

In addition to giving an illuminating history of wilderness programs, Bettman and her group describe an element of treatment that is sometimes necessary for those with substance disorders: enforced sobriety. The need for external limits for substance-abusing teenagers creates a tension for psychoanalysts, who generally try to help patients with improving their own inner control. The therapists in the wilderness program use their time with patients, who are a captive audience, to encourage them to understand their difficulties in greater depth.

In a related vein, Vaillant, known for his longitudinal research on alcoholism, felt that three components of treatment were necessary for effective treatment of addiction: external control such as drug or alcohol testing, a substitute dependency such as attending AA, and new relationships with sober peers (Vaillant and Milofsky 1982). These factors may assist in the treatment of substance dependence, in concert with psychoanalytically oriented work.

Developmental aspects of treatment

Why are substance misuse and dependence endemic in late adolescence and young adulthood? The movement toward independence, involving the creation of a sexual and a work identity, is a challenge for adolescents.

Rex McGehee provides an essay that integrates psychoanalytic and neuroscientific findings on adolescent development with research on the effects of chronic marijuana use. He explains why chronic use may be particularly hazardous during adolescence. Like the other contributors, he describes the difficulty of handling the denial and avoidance which accompany substance dependence. His description of the modifications of treatment necessary for adolescent substance abusers is especially helpful. He recommends that psychoanalysts provide some information about the negative effects of drug use to their patients. Furthermore, Dr. McGehee writes of the importance of patience, persistence, and outreach when the patient with substance abuse loses contact, an enactment that is often experienced by those who work with adolescent substance abusers.

We hope that you will find these articles stimulating, enlightening, and useful. We are grateful to the authors for sharing their empathy, wisdom, and insight regarding the treatment of those with substance abuse.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Laura Whitman

Laura Whitman, M.D., is a child, adolescent and adult psychoanalyst. She is in private practice on the upper west side of Manhattan, in person or by tele-medicine. She is a recipient of the 2020 Edith Sabshin teaching award form APsaA.

Wendy Olesker

Wendy Olesker, Ph.D., is a Training and Supervising Analyst at the New York Psychoanalytic Institute and on the Faculty at the NYU Postdoctoral Program in Psychoanalysis and Psychotherapy. She is Senior Editor of The Psychoanalytic Study of the Child. Presently and for the last 15 years she is Director of the Postdoctoral Fellowship Program at the New York Psychoanalytic Institute.