A developmental model of addictions, and its relationship to the twelve step program of alcoholics anonymous

Drive and Instinct-How They Produce Relatedness and Addiction

Addictive drugs are responsible for mass killing. Neither persons with addiction nor the general populace seem conscious of the malevolence of governments and drug dealers working together. How could this be? What is the place of psychoanalysis in thinking about deaths from addiction and in responding to patients with addiction? To answer these questions, we revise concepts of SEEKING, drive, instinct, pleasure, and unpleasure as separable. We review the neurobiological mechanism of cathexis. We discuss how addictive drugs take over the will by changing the SEEKING system. We review how opioid tone in the central nervous system regulates human relationships and how this endogenous hormonal system is modified by external opioid administration. We differentiate the pleasure of relatedness from the unpleasure of urgent need including the urgent need for drugs. We show how addictive drug-induced changes in the SEEKING system diminish dopaminergic tone, reducing the motivation to engage in the pursuit of food, water, sex, sleep, and relationships in favor of addictive drugs. With this neuropsychoanalytic understanding of how drugs work, we become more confidently conscious of our ability to respond individually and socially.

Do changes in selfishness explain 12-step benefit? A prospective lagged analysis

12-Step attendance is associated with increased abstinence. A strong claim made in 12-step literature is that alcoholics are pathologically selfish and that working the 12 steps reduces this selfishness, which, in turn, leads to sustained alcohol abstinence. This study tested this assumption by investigating the linkages between 12-step attendance, pathological narcissism, and drinking. One hundred thirty early Alcohol Anonymous (AA) affiliates with limited AA and treatment histories were recruited from treatment and community-based AA. A majority of the sample was alcohol dependent and reported illicit drug use before recruitment. Participants were interviewed at intake and at 3, 6, and 9 months. A majority of participants attended AA meetings throughout follow-up and such attendance predicted increased abstinence and reduced drinking intensity. 12-Step affiliates were significantly higher on pathological narcissism (PN) relative to general population samples and their PN remained elevated. Contrary to predictions, PN was unrelated to 12-step meeting attendance and did not predict later abstinence or drinking intensity. The findings did not support the hypothesis that reductions in PN explain 12-step benefit. An alternative function for the emphasis placed on pathological selfishness in 12-step programs is discussed and a recommendation is made to use unobtrusive measures of selfishness in future research.

Do changes in selfishness explain 12-step benefit? A prospective lagged analysis

12-Step attendance is associated with increased abstinence. A strong claim made in 12-step literature is that alcoholics are pathologically selfish and that working the 12 steps reduces this selfishness, which, in turn, leads to sustained alcohol abstinence. This study tested this assumption by investigating the linkages between 12-step attendance, pathological narcissism, and drinking. One hundred thirty early Alcohol Anonymous (AA) affiliates with limited AA and treatment histories were recruited from treatment and community-based AA. A majority of the sample was alcohol dependent and reported illicit drug use before recruitment. Participants were interviewed at intake and at 3, 6, and 9 months. A majority of participants attended AA meetings throughout follow-up and such attendance predicted increased abstinence and reduced drinking intensity. 12-Step affiliates were significantly higher on pathological narcissism (PN) relative to general population samples and their PN remained elevated. Contrary to predictions, PN was unrelated to 12-step meeting attendance and did not predict later abstinence or drinking intensity. The findings did not support the hypothesis that reductions in PN explain 12-step benefit. An alternative function for the emphasis placed on pathological selfishness in 12-step programs is discussed and a recommendation is made to use unobtrusive measures of selfishness in future research.

Drug dreams: a neuropsychoanalytic hypothesis

Recent studies have shown that the ventral tegmental pathway stimulates both dreaming and drug craving. To investigate a possible clinical link between these two psychic phenomena, psychotherapy notes from the first six months of an addicted patient's treatment were reviewed, together with verbatim notes from the four years of psychoanalysis that followed. Of 240 dreams reported by the patient,58 had manifest content involving the seeking or using of drugs. There was no particular temporal or emotional thematic pattern to these "drug dreams,"which persisted through four and a half years of sobriety. Drug dreams are observable phenomena that reflect both the innate structure of the brain and neural changes produced by exposure to addictive drugs. In some addicted persons, exposure to drugs produces a fixed change in neurological functioning with which they must contend for years, possibly the rest of their lives. Drug craving meets Freud's defining characteristics for a drive: it is a constant pressure, originating from within the organism, to do work, and it constantly demands satisfaction. Because ego and libidinal drives share a common neural pathway, they should not be separated conceptually. Solms's finding (in press) that the activating systems for dreaming and for craving are identical, a finding based on observations of tumor- or stroke-provoked brain lesions, is confirmed by observation of the dreams of a patient whose brain changes were created by drug exposure. This study provides further evidence that the origin of the dream is a wish.

Three perspectives on addiction

Three perspectives on addiction promulgated during the 1990s are reviewed, along with many earlier contributions to the understanding of addictive illness. It is suggested that these distinct yet overlapping formulations of the dynamics of addiction form a hierarchy for each patient suffering from an addiction. Assessment of a patient's ego strength, and of the relative importance of addictive behaviors in overall character structure, allows referral to various types of treatment, including psychoanalytic therapy. Case examples are presented, including material from the psychoanalysis of a woman addicted to heroin, methadone, cocaine, amphetamines, nicotine, alcohol, and shopping.

Psychodynamic psychotherapy of the intravenous cocaine abuser

Using the psychodynamic psychotherapeutic treatment of a 23 year old female cocaine-addicted client as an example, the author describes the theoretical concepts and clinical methods he has found useful in this context. Using an approach that draws on the work of Winnicott (1971, 1986, 1992) and Malan (1979), the author describes how psychodynamic psychotherapy can be effective in facilitating change in an addiction in an outpatient setting. Winnicott's work provides the context for the treatment while Malan's model provides a structure for the therapeutic process. Within the context of a holding environment, links between past trauma and current drug use as a defence are explored. Also discussed are the use of dream material, the facilitation of the corrective emotional experience, and the complementary use of 12-step programs in the therapeutic process.

Group intervention with pre-recovery patients

This article examines treatment outcomes of alcohol and drug abusing patients admitted to a university-based alcohol and drug outpatient clinic. Treatment effectiveness of two treatment models were evaluated. The psycho-educational approach utilized a teacher-student model with the goal of imparting information about drugs and consequences of use. The recovery-oriented approach utilized a patient-counselor collaborative model where patients were encouraged to be active in progressing through sequential stages of pre-recovery tasks. Patients in the psycho-education group stayed in treatment longer and were more likely to rate treatment as useful. Results showed minimal differences between the two groups in terms of Addiction Severity Index scores, Drug Attitude, and urine drug screen results.