by Harlan Matusow, PhD, LP, Faculty, CHD
May 9, 2019
What does modern psychoanalysis have to tell us about treatment for addictive disorders?
The starting point for any psychotherapeutic treatment is helping a patient describe both the circumstances that initiated use and those that perpetuate it. According to the National Institute on Drug Abuse, people begin taking drugs for one or some combination of the following: feeling good (getting high); feeling better (relieving stress); doing better (improving performance); curiosity; and peer pressure.
In 1986, the musician Robert Palmer observed a cluster of symptoms including sweating, shaking, disorientation, irregular heartbeat, and extreme agitation. He offered a diagnosis: You’re addicted to love! While evocative as a lyric and a notion, love addiction is only a poetic diagnosis. Mr. Palmer was describing symptoms of withdrawal, which are associated with physical dependence, a frequent component of addiction, but not addiction itself (to be fair, “Might as well face it, you’re in withdrawal!” would have made for a terrible song).
So let’s clarify some key terms: 1. Addiction, 2. Withdrawal, 3. Dependence, 4. Compulsion.
Addiction describes excessive, ongoing use of one or more psychoactive substances despite significant harm to oneself. It is associated with a cycle of compulsive use, dependence upon the substance, and symptoms of withdrawal upon its immediate cessation. Addiction frequently leads to financial and professional disruptions, ruptures in relationships, and negative health implications including disability and death.
Withdrawal describes the constellation of symptoms that occur upon the abrupt discontinuation or decrease in intake of medications or recreational drugs. Withdrawal occurs because over time, the body becomes habituated to and dependent upon certain chemicals (such as opioids, alcohol, and nicotine).
Dependence describes a state of physical reliance upon one or more chemicals for one’s ongoing health or comfort. One may be dependent on insulin; one may be dependent on alcohol. One can be dependent without being addicted. However, one cannot be addicted without being dependent. Some dependencies result in compulsive use of a substance, but not all compulsive activities are associated with physical dependence.
Compulsion refers to an irresistible urge to behave in a certain way, frequently against one’s conscious or stated wishes. If the compulsion is not satisfied, there is no physical withdrawal; there may be considerable emotional discomfort, however. An addictive disorder to gamble may ruin someone’s life as easily as alcohol use disorder (AUD). A difference is that AUD has a clear physiological component (habituation, dependence, withdrawal); gambling disorder does not.
The disease model and stigma
The disease model, consonant with the tenets of Alcoholics Anonymous and other mutual aid groups, describes addiction as a disease with biological, neurological, genetic, and environmental sources of origin. Critics of the disease model object to the stigmatizing effect of being labeled as “afflicted”. A victim of a disease, they argue, is blameless and powerless, neither of which lends itself to self-empowerment. And what disease, it is argued, starts with a “choice”, like snorting a crushed OxyContin or drinking a shot of bourbon from your parents’ liquor cabinet? Well, it’s like this: Diseases such as diabetes, cancer, and asthma, like addictive disorders, have both environmental and genetic underpinnings. In the same way reducing your smoking may help you avoid cancer; reducing your opioid usage may help you avoid opioid use disorder (OUD). No one expects or chooses to get hooked or to get cancer when they make the initial choice to feel good, to feel better, to do better, or to succumb to peer pressure. These are decisions made in the moment, not as a result of careful–or frequently any–deliberation.
For the modern analyst, as for Shakespeare’s Antonio, what’s past is prologue: The events of our lives have brought us to this point in time and circumstance; we cannot simply deal with the current problem without first gaining some grasp on the events of the past. Helping our patients describe their formative experiences–the choices they made in their childhood and those that were made for them–is the starting point for clarifying the role of addictive behavior in their current life. Why? Because a deliberative, respectful, investigative discussion of the environment in which substance misuse took root can ignite the process of diluting the harsh self-recrimination that is the hallmark of so many people who suffer with addictive disorders.
And the essential ingredient for moving past one’s addiction? Developing the capacity to endure the unspeakable discomfort and craving associated with the absence of the object of one’s desire. Every minute, every hour, every day, and every year until the hunger and yearning subside; until the rewards of rediscovering oneself, and the joy of reclaiming long-forgotten goals becomes self-reinforcing. For some, the ability to withstand the craving for immediate symptom relief is immediate. We all know someone who says, “I made the decision not to smoke anymore, and I simply walked away.” For most others, however, the process of quitting cold turkey is not a feasible option. For some, avoiding their substance of choice remains a lifelong challenge, which is why 28-day rehab is folly. Ninety percent of individuals who are detoxed and treated in such facilities relapse.
While effective medications exist to help diminish craving–especially for those recovering from alcohol or opioid dependence–the motor force behind sustaining momentum to live life free from addictive disorders is faith. Not faith in terms of God (although nothing wrong with religious catalysts to self-improvement), but faith that things will improve in unknowable ways if one can withstand the sheer agony of eschewing that which provides comfort and familiarity. A modern analyst is there to remind their patient of their long-term goals, their value to humanity, and the sanctity of each moment, and to share their pain and joy as they reawaken and find new meaning in life.